... College Students Perception of Personal Interoceptive Awareness Regarding Stress and Coping Submitted to the Faculty of the College of Health Sciences University of Indianapolis In partial fulfillment of the requirements for the degree Doctor of Health Science By: Stephanie L. Phares, MOT, OTR/L Copyright December 6, 2023 By: Stephanie L. Phares, MOT, OTR/L All rights reserved Approved by: Jennifer Fogo Burhenn, PhD, OTR Committee Chair ______________________________ Stephanie Kelly, PT, PhD Committee Member ______________________________ Kelly Mahler, OTD, OTR/L Committee Member ______________________________ Accepted by: Lisa Borrero, PhD, FAGHE Director, DHSc Program University of Indianapolis ______________________________ Stephanie Kelly, PT, PhD Dean, College of Health Sciences University of Indianapolis ______________________________ INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS College Students Perception of Personal Interoceptive Awareness Regarding Stress and Coping Stephanie Phares Department of Interprofessional Health and Aging Studies, University of Indianapolis 1 INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 2 Abstract Objective: College students experience stress due to numerous life transitions and changes between ages 18 and 24, in addition to the rise of mental health diagnoses for this age group. Coping with stress requires an individual to complete internal and external appraisals and respond accordingly. Interoceptive awareness (IA) is part of the internal appraisal process. Understanding the IA of college students may help to improve coping skills within this population. Method: Eight participants from a mid-sized, private, Midwestern university participated in a semi-structured interview regarding their lived experience with stress, coping, and IA. Utilizing interpretive phenomenological analysis, two primary themes and several subthemes emerged. Results: Theme one, IA and experiences of stress, contained sub-themes relating to IA:1) the physiological effects of stress, 2) the effects of stress on eating behaviors and levels of arousal, 3) the interpretation and the impact of stress on daily life, and 4) ways participants know they are no longer experiencing stress. Theme two, coping strategies, covers helpful and not helpful means of managing stress. Conclusion: After education on IA, the participants discussed more bodily sensations in relation to stress. The researcher suggests a follow-up survey may provide data on whether or not education on IA affected the awareness of stress and coping strategies of the participants. Education on IA, in general, may improve how individuals understand their bodily signals. Learning to interpret personal IA appropriately can improve stress management, coping strategies, social participation, emotional regulation, and academic performance. Keywords: interoception, interoceptive awareness, emotional regulation, coping INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 3 Acknowledgements I am thankful for the lessons I have learned, the organizational skills I picked up along the way, and the beautiful people who helped me reach my goal. Without each of them, I know I would not have made it this far! First, I would like to thank the faculty and staff at the University of Indianapolis who helped me shape my dissertation topic. Dr. Santurri, Dr. Borrero, and Dr. Stith all assisted me in exploring and then narrowing my topic into something manageable. My dissertation committee members helped me to stay on target and be realistic about this process. I am grateful to Dr. Jennifer Fogo Burhenn, my committee chair. She talked me through the process, answering phone calls and texts and helping me organize my scattered thoughts. Dr. Stephanie Kelly guided me through navigating the data and deciding what was genuinely relevant to the research. Finally, I could not have asked for a more qualified content expert. Without the breadth of research and advocacy Dr. Kelly Mahler has dedicated her career, I may not have been aware of interoceptive awareness's importance in our lives. Dr. Mahler was kind, patient, and encouraging throughout the entire process. I was overjoyed she entertained meeting with me, let alone agreeing to be my content expert! The guidance and feedback of my committee helped shape the research study into something I really enjoyed completing. My fellow classmates helped me maintain my sanity throughout this process as well. I am grateful to all of my group mates for having such dedication and focus on our work. I looked forward to getting on virtual meetings with them. It made me feel connected and not so alone in this process. However, I would like to give a special thanks to Elizabeth Harvey and Earlene Masi. Our weekly meetings are what got me through Statistics and through the program. The love and support these women have given me is something for which I am truly grateful. I am thankful we still connect out of enjoyment rather than to complete an assignment. INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 4 Most importantly, I would like to thank my family. You kept me sane and grounded. Paul, you have taken the lions share of responsibility and work these last three and a half years. I am so thankful for you. You are a loving, encouraging, and supportive partner. I seriously would not have made it this far without you. Zee and Luke, your humor helped keep things in perspective for me. We will be joking about IBM SPSS for many years to come!!! Most importantly, your understanding of my going back to school helped our household run smoothly. INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 5 Table of Contents Problem Statement ...................................................................................................................... 9 Purpose Statement ....................................................................................................................... 9 Research Questions ................................................................................................................... 10 Significance of the Study .......................................................................................................... 10 Definition of Terms ................................................................................................................... 10 Literature Review.......................................................................................................................... 11 College Students and Mental Health ......................................................................................... 12 Stress and Coping ...................................................................................................................... 13 Sensory Awareness, Interoception, and Emotional Regulation ................................................ 14 Mental Health Supports for Undergraduate Student Population............................................... 16 Current Services Available on College Campuses ................................................................ 17 Occupational Therapy as a Support to College Students ...................................................... 18 Method .......................................................................................................................................... 20 Study Design ............................................................................................................................. 20 Participants ................................................................................................................................ 20 Setting........................................................................................................................................ 21 Procedures ................................................................................................................................. 21 Sampling and Recruitment .................................................................................................... 21 Informed Consent .................................................................................................................. 22 Data Collection ...................................................................................................................... 22 Data Management & Analysis ............................................................................................... 23 Rigor & Trustworthiness ........................................................................................................... 25 Results ........................................................................................................................................... 26 Overview of Findings ................................................................................................................ 27 Interoceptive Awareness and Experiences of Stress ................................................................. 29 The Physiological Sensations Related to the Experience of Stress ....................................... 31 Impact of Stress on Appetite, Eating Behaviors, and Levels of Arousal .............................. 31 Experience of Stress and the Impact of Stress on Daily Life ................................................ 36 Interoceptive Awareness When No Longer Experiencing Stress .......................................... 39 Coping Strategies ...................................................................................................................... 41 Helpful Coping Strategies ..................................................................................................... 41 INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 6 Not Helpful Coping Strategies .............................................................................................. 42 Discussion ..................................................................................................................................... 44 Personal Interoceptive Awareness When Experiencing Stress ............................................. 45 Role of Personal Interoceptive Awareness in Preferred Coping Strategies .......................... 48 Connecting IA to Undergraduate College Students Lived Experience with Stress ............. 51 Limitations ................................................................................................................................ 53 Real World Implications ........................................................................................................... 53 Future Research ......................................................................................................................... 54 Conclusion .................................................................................................................................... 55 Researchers Self-Reflection Statement ....................................................................................... 55 Human Subjects Statement........................................................................................................ 57 References ..................................................................................................................................... 58 Tables ............................................................................................................................................ 67 Table 1 ....................................................................................................................................... 67 Demographic Information on Participants ............................................................................ 67 Table 2 ....................................................................................................................................... 68 Sample of Themes Emerging from the College Students Perceptions of Personal Interoceptive Awareness Regarding Stress and Coping Interviews ...................................... 68 Figures........................................................................................................................................... 73 Figure 1 ..................................................................................................................................... 73 Interoceptive Awareness in Regards to Stress and Coping ................................................... 73 Appendices .................................................................................................................................... 74 Appendix A ................................................................................................................................... 74 Informed Consent Document for Research Study Participation ................................................... 74 Appendix B ................................................................................................................................... 79 Recruitment Flyer ......................................................................................................................... 79 Appendix C ................................................................................................................................... 80 Information Sheet.......................................................................................................................... 80 Appendix D ................................................................................................................................... 81 Google Form ................................................................................................................................. 81 Appendix E ................................................................................................................................... 82 Interview Guide ......................................................................................................................... 82 Interview Guide Questions ........................................................................................................ 83 INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 7 Appendix F.................................................................................................................................... 85 Interview Descriptive Summaries ................................................................................................. 85 A ................................................................................................................................................ 85 B ................................................................................................................................................ 87 C ................................................................................................................................................ 89 D ................................................................................................................................................ 91 E ................................................................................................................................................ 93 F................................................................................................................................................. 95 G ................................................................................................................................................ 97 H ................................................................................................................................................ 99 INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 8 College Students Perception of Personal IA Regarding Stress and Coping By age 24, up to 75% of people will experience a mental health condition (National Alliance on Mental Illness [NAMI], 2022). Students with a mental health diagnosis make up one-third of college students with disabilities (Spencer et al., 2018) and 64% of these students are likely to leave college without graduating (Gruttadaro & Crudo, 2012). Mental health affects mood, emotions, thinking patterns (Spencer et al., 2018), sensory processing (Bailliard & Whigham, 2017), and interoception (Critchley & Garfinkel, 2017; Khalsa et al., 2018). Interoceptive awareness (IA) provides information about the physiological state of the body, such as appetite, heart rate, and energy levels, and has evidence linked to emotional processing (Critchley & Garfinkel, 2017; Khalsa et al., 2018; Price & Hooven, 2018; Schmitt & Schoen, 2022; Schuette et al., 2021; Uddin et al., 2017). People who are more aware of their interoceptive signals typically have better emotional regulation (Critchley & Garfinkel, 2017; Price & Hooven, 2018; Schmitt & Schoen, 2022; Schuette et al., 2021). Better emotional regulation improves stress management and coping skills (Price & Hooven, 2018; Schuette et al., 2021; Wethington et al., 2015). College students who struggle to manage their stress can experience disruption in their ability to function daily (Amanvermez et al., 2021; Bistricky et al., 2018). Students may not realize they are under stress until they are overwhelmed and in academic distress, presenting as poor attendance, an inability to maintain an appropriate grade point average, or struggling to complete daily tasks. Services available to college students on campus often include basic counseling, workshops, and educational sessions regarding stress management (Amanvermez et al., 2021). Even with supports in place, many college students are still at risk of experiencing unmanaged stress (Bistricky et al., 2018). While many professions focus on coping skills and INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 9 stress management, an occupational therapist promotes awareness of interoceptive signals within a framework that relates IA to daily life (Khalsa et al., 2018; Schmitt & Schoen, 2022). Exploring the role of interoception awareness in connection with emotional regulation can improve coping skills and stress management (Price & Hooven, 2018), a goal for promoting healthy campuses (American College Health Association [ACHA], 2020). Problem Statement How a student chooses to cope with stress will affect their behaviors, emotions, relationships, physical well-being, and academic endeavors (Boke et al., 2019). Prior research has shown the link between IA and emotional regulation (Price & Hooven, 2018; Schmitt & Schoen, 2022). Consideration of the student stress experience is key to understanding their stress profile and subsequent treatment strategies (Boke et al., 2019). Without addressing IA, students may not realize they are under stress until they are overwhelmed and in academic distress, presenting as poor attendance, an inability to maintain an appropriate grade point average, or struggling to complete daily tasks. Current research addressing college students lived experience with stress does not explore the relationships between IA, stress management, and coping (Amanvermez et al., 2021; Bistricky et al., 2018; Boke et al., 2019; Rodriguez & Provident, 2018; Sapadin & Hollander, 2021; Shi, 2019; Straud & McNaughton-Cassill, 2019; Yzer & Gilasevitch, 2019). An opportunity exists to understand how IA influences stress and coping abilities in college students. Purpose Statement This interpretive phenomenological study aims to understand whether undergraduate college students aged 18-24 who live on campus use IA to identify when they experience stress and engage in chosen coping strategies. INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 10 Research Questions 1. What is the personal IA of undergraduate college students aged 18-24 when experiencing stress? a. How do undergraduate college students interpret their personal physiological interoceptive sensations when experiencing stress? b. What is the undergraduate college students perception of personal physiological interoceptive signals when experiencing stress? 2. What role does personal IA play when engaging in preferred coping strategies in undergraduate college students aged 18-24? a. How does personal IA inform undergraduate college students when choosing coping strategies? b. How does personal IA affect continued engagement with preferred coping strategies to manage stress? Significance of the Study By understanding students' perspectives on personal IA with stress and coping, college campuses can explore integrating IA into mental health interventions. Studying the link between IA and stress management in college students may have an impact on overall student wellness, academic performance, and coping strategies. Additionally, occupational therapy practitioners may expand services on college campuses to address students interoceptive needs. Thus improving college students stress management and overall quality of life. Definition of Terms INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 11 Emotion(al) Regulation: The ability to create an appropriate emotional response to a situation based on internal cues and external demands or circumstances (Price & Hooven, 2018). Interoception: How the brain senses, receives, understands, and categorizes the physiological signals it receives from the body, conscious and unconsciously, then interprets them into an emotional state or feeling (Khalsa et al., 2018; Quigley et al., 2021; Uddin et al., 2017). Detection of changes comes from sensory receptors on the internal organs (American Occupational Therapy Association [AOTA], 2020). Interoceptive awareness (IA): The ability to become consciously aware of the interoception signals from the body and integrate those signals with cognition and emotional responses (Price & Hooven, 2018). Literature Review Mental health issues can negatively influence college students' academic success (Amanvermez et al., 2021; Bke et al., 2019; Rodriguez & Provident, 2018; Straud & McNaughton-Cassill, 2019). Learning what factors contribute to stress externally and internally can help students manage stress and cope appropriately. External factors include deadlines, noisy study areas, and annoying roommates. Internal factors include feeling cold, tired, and hungry, also known as interoception (Critchley & Garfinkel, 2017; Khalsa et al., 2017). For example, a person who is aware of being cold or hungry will seek heat or food respectively when they understand those signals from the body (Paulas & Stewart, 2014). IA gives a person the ability to acknowledge those bodily signals, discern the signals meaning, and manage emotions accordingly (Schuette et al., 2021). A person with IA may notice a racing heartbeat with increased anxiety and explore ways to decrease their anxiety (Schuette et al. 2021). INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 12 Misinterpreting or not noticing the bodys cues is common, leading to greater stress levels and poor emotional regulation (Schuette et al., 2021). The ability to regulate emotions leads to better executive functioning skills, social skills, and problem-solving skills (Pinna & Edwards, 2020). Students have access to counseling centers but do not always seek help when needed (Amanvermez et al., 2021; Gruttadaro & Crudo, 2012; Pedrelli et al., 2015; Shi, 2019). Understanding how undergraduate students experience and perceive stress, using IA, may improve services available on campus to ensure academic success. This literature review focuses on the mental health status of undergraduate college students, the connections between interoception, emotional regulation, stress management, and coping, current trends in services available on campus, and the role occupational therapy can play on college campuses. College Students and Mental Health The typical age for traditional college students is 18 to 24 (The Hamilton Project, 2017). Most people with a mental health diagnosis will experience onset before age 25 (NAMI, 2022; Pedrelli et al., 2015). According to the Diagnostic and Statistical Manual of Mental Disorders, 5th ed (DSM-5) (American Psychiatry Association [APA], 2013), common diagnoses within the college age population include attention-deficit hyperactivity disorder (ADHD), bipolar disorder, autism spectrum disorder (ASD), learning disabilities (LD), eating disorders (ED), depression, and anxiety disorders (Pedrelli et al., 2019; Schindler, 2019; Yzer & Gilasevitch, 2019). Anxiety and depression are the most prevalent among young adults (Bke et al., 2019; Pedrelli et al., 2015; Shi, 2019; Yzer & Gilasevitch, 2019). Stress is rising among college students, which can lead to difficulty in maintaining daily functioning when living independently (Bistricky et al., 2018). Skills required to live independently include money management, laundry, meal preparation, and school-life balance INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 13 (DAmarco et al., 2018). Schindler (2019) reported that success in college requires problemsolving skills, organizational skills, concentration skills, and judgment, in addition to having personal awareness when setting goals and advocating for self. According to numerous studies, the most common stressors within this population include living independently for the first time, navigating roommates and serious relationships, working, managing bills, choosing a career path, and maintaining satisfactory academic standing (Amanvermez et al., 2021; Bistricky et al., 2018; Pedrelli et al., 2015; Schindler, 2019; Shi, 2019). Living with extreme levels of stress or a mental health diagnosis makes it even more difficult to function in these capacities (Schindler, 2019; Yzer & Gilasevitch, 2019). Good performance in higher education requires students to be disciplined and responsible for maintaining attendance. College classes often do not meet daily, schedules can have significant breaks, and assignments require time management skills to meet deadlines (Schindler, 2019). Numerous studies credit the stress students experience in college as a source of low academic performance, relational issues, and contributes to increased college dropout rates (Amanvermez et al., 2021; Bke et al., 2019; Rodriguez & Provident, 2018; Schindler, 2019; Straud & McNaughton-Cassill, 2019; Yzer & Gilasevitch, 2019). Understanding the importance of stress management and effective coping strategies is key to academic success (Rodriguez & Provident, 2018). Stress and Coping According to the World Health Organization (WHO, 2021), stress is how the body responds to something physical, emotional, or psychological that requires action or attention from the person. College students who do not manage their stress effectively are more likely to develop depression, anxiety, substance use, and panic attacks (Bke et al., 2019; Shi, 2019; Yzer INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 14 & Gilasevitch, 2019). Numerous studies have referenced the seminal research of Lazarus and Folkman (1984), stating managing stress and coping relies on a person's ability to understand the external demands of a situation along with possessing the internal capacity and resources to respond (Bke et al., 2019; Folkman et al., 1986; Lewis-Kipkulei et al., 2021; Straud & McNaughton-Cassill, 2019; Wethington et al., 2015). Identifying a stressor and possessing the ability to cope is a continual undertaking necessary for survival (Folkman et al., 1986). The process of coping requires a person to appraise the situation, maintain emotional regulation, and sustain efforts to achieve the desired outcomes (Straud & McNaughton-Cassill, 2019; Wethington et al., 2015). Successful coping requires a person to have an awareness of internal and external input, and then respond accordingly (Bke et al., 2019; Lewis-Kipkulei et al., 2021). A person uses external appraisal to examine the environment and demands of the situation or task (Bke et al., 2019; Folkman et al., 1986; Lewis-Kipkulei et al., 2021; Straud & McNaughton-Cassill, 2019; Wethington et al., 2015). Internal appraisal requires a person to understand their bodily sensations, emotional state, and coping strategies available (Bke et al., 2019; Folkman et al., 1986). Seeking information, problem solving, avoidance, denial, revising goals, and utilizing support systems are common forms of coping (Wethington et al., 2015). Personal awareness of an emotional state requires a person to understand their physiological reaction to the stressor and interpret it by their response to the stressor (Critchley & Garfinkel, 2017). In addition to understanding when a situation is stressful, a person must also interpret internal bodily sensations and sensory input, which can affect stress levels regardless of the persons awareness of them. Sensory Awareness, Interoception, and Emotional Regulation INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 15 A leading pioneer in occupational therapy, A. Jean Ayers (1979), developed the sensory integration theory to describe how the brain interprets sensory input from the environment and the body. Over time, sensory processing and modulation have been included to expand the concept of sensory experiences. Sensory processing refers to how information like touch, sight, taste, smell, and sound are processed, and sensory modulation refers to how the person adapts and responds to that information (Craswell et al., 2020). People have individual sensory preferences and thresholds, which influence mood and emotional expression, activity and environmental setup preferences, and overall daily functioning (Craswell et al., 2020; Dunn, 2001; Metz et al., 2019). Some researchers noted that people who experience depression or anxiety disorders demonstrated increased sensory processing difficulties, thus affecting their ability to function in daily life (Billiard, 2015; Metz et al., 2019). Further sensory experience research revealed numerous studies referring to interoception as the awareness of bodily sensations and physiological needs, allowing for appropriate appraisal and response to that input, or IA (Adolfi et al., 2017; Arora et al., 2020; Craig, 2002; Critchley & Garfinkel, 2017; Farb et al., 2020; Khalsa et al., 2018; Pinna & Edwards, 2020; Price & Hooven, 2018; Schutte et al., 2021; Uddin et al., 2017). These bodily sensations and physiological needs refer to the information received from areas such as the heart, gut, bowels, skin, and lungs, resulting in experiences including pain, hunger, and changes in heart rate (Critchley & Garfinkel, 2017; Khalsa et al., 2017; Uddin et al., 2017). These same findings connect interoception to emotional awareness and the outward expression of emotions, or emotional regulation (Adolfi et al., 2017; Arora et al., 2020; Craig, 2002; Critchley & Garfinkel, 2017; Farb et al., 2020; Khalsa et al., 2018; Pinna & Edwards, 2020; Price & Hooven, 2018; Schuette et al., 2021; Uddin et al., 2017). INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 16 IA requires the brain to evaluate the body's sensations (Craig, 2002) and interpret those sensations into an emotional response to stressors (Price & Hooven, 2018). The process requires the ability to accurately detect, attend to, and interpret interoceptive cues with discernment, insight, and awareness of the sensitivity or intensiveness of the signal (Khalsa et al., 2018). Successful emotional regulation requires the person to be aware of and manage interoceptive input from the body (Adolfi et al., 2017; Craig, 2002; Critchley & Garfinkel, 2017; Farb et al., 2020; Khalsa et al., 2018; Pinna & Edwards, 2020; Price & Hooven, 2018; Schuette et al., 2021; Uddin et al., 2017). Interoception is connected to the autonomic nervous system (ANS) and the expression of emotion, as demonstrated by an emotional and physiological reaction to a situation such as anger with a red face, racing pulse, and flushed skin (Pinna & Edwards, 2020). Other physiological sensations related to IA include hunger (Stevenson et al., 2023) and levels of arousal related to the sensation of being tired (Arora et al., 2020). Poor IA, either heightened or dulled awareness, is linked to the diagnoses of schizophrenia, depression, anxiety, eating disorders, post-traumatic stress disorder, and chronic pain disorders (Bonaz et al., 2021; Khalsa et al., 2017; Nord & Garfinkel, 2022). While the authors agree more research is necessary, poor IA can also directly affect sleep, eating habits, substance use, and nonsuicidal self-harm (Arora et al., 2020; Paulas & Stewart, 2014; Stevenson et al., 2023; Young et al., 2021). A person who can use emotional regulation and coping strategies will successfully appraise the situation and respond efficiently (Pinna & Edwards, 2020; Price & Hooven, 2018). Thus, successful stress management and coping strategies hinge on being aware of and managing internal appraisals and IA. Mental Health Supports for Undergraduate Student Population INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 17 The American College Health Association (ACHA, 2020) created the Healthy Campus Framework to provide recommendations for campus environments that support all students' physical and mental health. Researchers report a shortfall in studies that examine the students perceptions and understanding of stress and coping strategies (Amanvermez et al., 2021; Shi, 2019; Yzer & & Gilasevitch, 2019). Shi (2019) reported that 28% of college students responding to a stress management survey indicated they felt unable to manage their stress. Moreover, many of those respondents reported being aware of stress management techniques but could still benefit from actively engaging in stress reduction strategies (Shi, 2019). Shi (2019) noted that students with awareness of the risks of stress engaged in more information seeking behaviors to manage their stress. Amanvermez et al. (2021) acknowledged that while college students benefitted from evidence-based stress management programs, universities needed to address barriers to seeking help among the student body. Sapadin & Hollander (2021) reported a need for early intervention services to decrease the demand for crisis services on college campuses. The authors suggested early intervention strategies promote improved emotional regulation for healthier coping strategies among college students (Sapadin & Hollander, 2021). Current Services Available on College Campuses Many colleges and universities have counseling services for students to access for support, counseling, or treatment for a mental health diagnosis (Amanvermez et al., 2021). Most services focus on cognitive interventions and health behaviors to address stress management (Amanvermez et al., 2021; Bistricky et al., 2018). College counseling services report a growing number of students seeking counseling or services provided by the university (Mazurek Melnyk et al., 2016; Sapadin & Hollander, 2021; Straud & McNaughton-Cassill, 2019; Yzer & Gilasevitch, 2019). Sapadin and Hollander (2021) reported an increase in the number of students INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 18 seeking crisis services since 2015, requiring university counseling services to spend more time completing crisis assessments, making referrals for other services, and directly admitting students to hospital services. The authors noted that responding to crises requires counselors to cancel scheduled appointments; further disrupting student services (Sapadin & Hollander, 2021). Counseling centers often feel overwhelmed and ill equipped to assist students with these growing demands (Mazurek Melnyk et al., 2016; Sapadin & Hollander, 2021; Straud & McNaughtonCassill, 2019; Yzer & Gilasevitch, 2019). Even though the number of college students seeking counseling services is growing, only a fraction of the students who could benefit utilize the available services (Amanverez et al., 2021; Gruttadaro & Crudo, 2012; Pedrelli et al., 2015; Shi, 2019). Gruttadaro and Crudo (2012) conducted a study focusing on college students and mental health and discovered that many college students who could have accessed their university counseling services did not. Students who left college reported being unaware of the services offered or did not think they needed the services (Amanvermez et al., 2021; Gruttadaro & Crudo, 2012). Some of the reasons students did not utilize services were a lack of information about what services were available, negative beliefs about seeking treatment, and a belief in the ability to manage the stress themselves (Amanvermez et al., 2021; Pedrelli et al., 2015; Shi, 2019). Increasing the availability of services and information leads to an increase in the number of students accessing support services provided by the university and counseling centers (Amanvermez et al., 2021; Gruttadaro & Crudo, 2012; Pedrelli et al., 2015; Shi, 2019). Occupational Therapy as a Support to College Students Occupational therapy (OT) practitioners have a long history of addressing mental health to facilitate active and full lives (AOTA, 2016). The occupational therapy scope of practice INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 19 focuses on a persons health, well-being, participation, and engagement in desired occupations (AOTA, 2020). Occupational therapy practitioners provide a variety of skills and occupationbased interventions to promote success in daily life (AOTA, 2020). Currently, occupational therapy practitioners who work on a college campus assist students with social interactions and life balance (Spencer et al., 2018). OTs assist with identifying academic skills necessary for success with the student. Assistance with skill acquisition may present as connecting a student to support services, promoting self-advocacy, providing assistance with identifying appropriate accommodations, and creating healthy habits and routines (Spencer et al., 2018). Another possible role for occupational therapy practitioners on college campuses is to bring awareness to interoceptive signals of college students while participating in occupations. College students engage in the occupations of health management, work, school, leisure, and social participation (AOTA, 2020). The Occupational Therapy Practice Framework: Domain and Process (4th Ed.) (AOTA, 2020) states managing emotions, expressing needs, and utilizing coping strategies are key factors to the occupation of health management. Other ways a person engages in the occupation of health management include self-care tasks like physical activity, nutrition management, and sexual health (AOTA, 2020). Appropriate health management allows for improved performance in the other roles college students occupy. Addressing student body mental health leads to a healthy campus (ACHA, 2020). Increasing general outreach and awareness of mental health services across the campus, not just for those who need it, can help reduce stigma and help students be more proactive in their care (Sapadin & Hollander, 2021). Stress management programs benefit students regardless of their levels of stress (Amanvermez et al., 2021). Gaining an understanding of how college students perceive IA as it relates to stress and coping can help improve stress management programs on INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 20 college campuses. Occupational therapy practitioners bring a wealth of knowledge and skills to the college population that can ease the role counseling centers play, contributing to a healthy campus community (ACHA, 2020; Spencer et al., 2018). Improving student stress management leads to improved occupational performance and participation, a benefit for the entire campus community. Method Study Design This interpretive phenomenological study seeks to understand and find shared meaning of college students perception of personal IA as it relates to experiencing stress and choosing coping strategies among undergraduate college students. Interpretive phenomenological research focuses on the lived experiences of a homogenous group with the probability of having a shared perspective of a phenomenon (Larkin et al., 2019). The collaboration between the researcher and participants allows for an exploration of the phenomenon on a deeper level (Smith & Fieldsend, 2021). The participant's descriptions of their awareness of personal interoception signals with stress and coping will provide an overall understanding of the phenomenon among college students aged 18-24 (Phillips-Pula et al., 2011). Institutional Review Board (IRB) permission granted before conducting any research study activity. Participants The inclusion criteria for this study were any residential undergraduate student aged 1824 years old. Exclusion criteria were students who did not speak or read English, as all study materials were in English. Any students living at home or off campus were also excluded due to familiar household schedules prompting them to eat or sleep. The typical age range for students INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 21 attending a four-year university or college is 18-24 (The Hamilton Project, 2017). Therefore, participants outside that age range are outliers and excluded from this research study. Setting The setting is a private, mid-sized Midwestern university that offers counseling services on campus. Procedures Sampling and Recruitment Purposeful homogenous sampling (Smith & Fieldsend, 2021) and snowball sampling (Smith et al., 2009) allowed the researcher to gather information to answer the research questions in a rich environment (Smith et al., 2009). A small sample size of eight students allowed the researcher to spend time detailing the richness of the data collected (Smith & Fieldsend, 2021). Participants were chosen based on demographic information to ensure a broad representation of the population (Smith & Fieldsend, 2021). The representation of the population was able to provide information on the convergence and divergence patterns that arise within the study of the phenomenon (Smith et al., 2009). Recruitment fliers were sent via an online weekly newsletter to the student body by the Associate Vice President for Academic and Student Affairs & Dean of Students, as well as posted in the Wellness and Recreation Center. The flyers described the general research study and contained a link and QR code to a Google Form for further information and participation. The Google Form provided inclusion and exclusion criteria to participate in the study, the estimated length of time for each interview, how the information will be collected and deidentified to protect participant privacy, demographic information, and the researchers email address and office phone number for questions. Demographic information included gender INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 22 identity, age, year in undergraduate studies, ethnicity, degree path, and distance from closest family or caregiver support. The individual completed the Google Form with contact information for the researcher to determine eligibility and schedule an interview. The researcher contacted interested participants via telephone as the form responses were received until the study had ten eligible participants to provide a breadth of data. However, only eight participants responded in the timeframe. Informed Consent The researcher provided interested parties verbal information regarding voluntary participation and withdrawal from the study, the purpose and procedures for the data collection, a confidentiality statement discussing personal privacy throughout the study, permission to record the interview, and any risks or benefits of the study to obtain consent when contacted about the study (Creswell & Poth, 2018). An information sheet containing this information was provided to the participant at the time of the interview. The researcher coded each participant at the time of consent to ensure personal privacy. This code was used to code audio recordings, printed transcripts, and field notes uniquely for each individual. Data Collection Data was collected via semi-structured interviews. Semi-structured interviews gave the researcher the ability to set an agenda for the interview but allowed the participant to expand upon their lived experience as necessary (Smith et al., 2009). Using an interview guide developed from the research on interoception, stress, and coping, the researcher explored stress and coping among residential undergraduate college students. The semi-structured interview guide contained broad, open-ended questions used to understand the perception and meaning placed on stress and coping regarding personal interoception. The sub-questions explored INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 23 whether or not interoception awareness factors into stress levels and chosen coping strategies. Prompts were used as needed to explore more detail and depth in the responses. The interview finished with questions focusing on how a person knows when they are no longer experiencing stress, current stress management, coping techniques, support systems, and if there is anything else they need in terms of helping them manage stress. Finally, the participants had opportunity to share anything else they thought was pertinent to the research. Interviews took place in person, on campus, in a familiar yet quiet location of the students choosing. Interviews lasted 25 to 35 minutes. The researcher used a digital recorder to collect audio from the in-person interviews. The researcher used a notebook to collect field notes for all interviews. Data Management & Analysis The interviews were transcribed via the dictation feature on Microsoft 365 Word. The researcher de-identified the transcripts by issuing the participants code to indicate when the participant is talking. The key that links the participants to their codes was kept in a locked filing cabinet behind a locked office door. Prior to listening to the recordings, the researcher engaged in bracketing to reduce researcher biases regarding personal experiences, beliefs, values, emotions, or thoughts regarding the phenomenon of interoception as it relates to stress and coping (Tufford & Newman, 2010). With the first review of the data, the researcher memoed and dated the bracketing at the top of each transcript to reduce bias. The researcher listened to the recordings numerous times to make manual corrections to the written transcripts to ensure the accuracy of the data. The researcher added observations of body language from the field notes to the transcript. The transcripts were uploaded to Dedoose (9), a password-protected data analysis INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 24 software (Dedoose, 2022), to begin the coding process. The researcher manually printed transcripts to facilitate ease of cross-referencing. All printed or written materials related to the study, such as transcripts, field notes, bracketed observations, and memos related to the interviews, were stored in a locked filing cabinet in the researcher's locked office. De-identified data analysis that occurred electronically was stored on the researchers password-protected computer in a locked office. Each participant had a password-protected electronic file and a hard file in a locked cabinet containing notes, memos, field notes, and report drafts (Groenewald, 2004). The data analysis process followed the steps for interpretive phenomenological analysis (IPA) described by Smith et al. (2009). Before exploring themes in the data analysis, the researcher typed memos in Dedoose (2022) and wrote on the transcripts; indicating bracketing took place before analyzing the data. The data analysis moved from focusing on each participant's individual statements and experiences to broader and more complex themes that focused on how all participants reported experiencing stress and coping (Creswell & Poth, 2018). The IPA process allows for analysis within cases and across cases to fully grasp and comprehend the participants' experience (Smith & Fieldsend, 2021). The researcher began by reading and rereading the data of one participant at a time to make that participant the focus of the analysis, which included occasionally listening to the recording while reading to highlight important or more profound sections of the data (Smith et al., 2009). The second step of IPA is initial noting. Smith et al. (2009) describe noting in the following process. While reading and re-reading the data, the researcher will begin exploratory commenting, noting anything of interest with descriptive, linguistic, and conceptual comments. Descriptive comments will focus on areas that highlight the structure of the participants INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 25 experience and deepen in meaning with each subsequent data review. Linguistic comments will pay attention to the language used, the repetition of phrases or words, and the use of metaphors. The researcher will use conceptual comments to note the participants overarching idea of the phenomenon (Smith et al., 2009). The researcher examined the units of meaning to develop clusters of common themes and significant topics representing coping and stress among each participant (Groenewald, 2004; Smith et al., 2009). These themes combined to create a descriptive summary of the phenomenon of stress and coping for each participant to ensure the essence of their experience is captured (Creswell & Poth, 2018). The researcher sent participants a descriptive summary of themes via password-protected email along with another copy of the transcript for reference. Once verified and corrected for accuracy, the researcher examined at the interviews collectively and identified commonalities and variations among participant experiences (Groenewald, 2004; Smith et al., 2009). The final report contains significant individual statements from the participants regarding their lived experience with stress and coping, the general themes that emerged, and a composite summary explaining the overarching essence of the phenomenon (Creswell & Poth, 2018; Smith et al., 2009). Rigor & Trustworthiness To establish rigor and trustworthiness, the researcher addressed credibility, transferability, dependability, and confirmability throughout the study (Henderson & Rheault, 2004). Purposive sampling, participants being encouraged to share their experiences, and member checking established credibility (Henderson & Rheault, 2004; Marshall & Rossman, 2011). The researcher used a field journal to collect notes on body language, facial expressions, and essential memos to the best of the researchers ability during the interview (Marshall & INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 26 Rossman, 2011). Member checking occurred through participants receiving the descriptive summary of the analysis of themes and interview transcripts, allowing for corrections. Bracketing occurred during data analysis to reduce researcher bias for credibility and confirmability (Henderson & Rheault, 2004). To further ensure credibility and dependability, structural coherence was employed with the interview guide, data analysis, and reporting of the results (Henderson & Rheault, 2004). Additional researchers with experience in qualitative research reviewed the interview guide to certify that the questions asked were pertinent to the research questions. Committee members also reviewed the data analysis to ensure the results accurately reflect the research questions and the participants' lived experiences (Creswell & Poth, 2018). Listening to the interviews repeatedly while making notes addressed dependability and credibility by corroborating themes and generalities in the data analysis to fully depict the phenomenon while reducing bias (Henderson & Rheault, 2004). Demographic information was collected for transferability purposes and not used in a way that identifies the participant. Transferability to other colleges and universities with similar settings and demographics occurred by ensuring the interview guide reflects the research questions and themes in the data analysis are general to coping and stress. Results Eight participants were interviewed for the research. Demographic information included gender identity, age, year in undergraduate study, ethnicity, and degree path (Table 1). Results show that 75% of participants identified as female and 25% as male. Fifty percent of participants were seniors in college, and 25% were freshmen. The remaining 25% of the participants split between sophomore and junior years in undergraduate studies. All participants identified their ethnicity as Caucasian, with one participant also identifying as Latina. Two participants were INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 27 studying communications, one was studying psychology and sociology, and all remaining participants were working towards some form of exercise science or exercise science and human performance degree. Interviews were conducted in person at the campus library, ranging from 25 to 40 minutes. Overview of Findings All interviews began with the interviewer asking the participants about their college experience thus far. The participants could differentiate their challenging and rewarding experiences while acknowledging their personal growth. Many participants formed new friendships and learned how to manage difficult situations. Extracurricular activities provided a space for connections and achieving personal goals. Academics served as a source of growth and stress, with many participants taking 16 credits or more. Participants discussed how they maneuvered through COVID-19 challenges, which they experienced at some point in their college transition. The participants describe multiple factors that contributed to their stress levels. These factors were consistent with those described in the literature and included academic load, managing friendships, and transitioning into college. The personal factors participants noted related to diagnosis, traces of perfectionism, being a high achiever, overloading their schedule, and the feeling of being in a constant state of stress. Four out of the eight participants selfreported mental health diagnoses among the participants were depression, anxiety, and attention deficit hyperactivity disorder (ADHD). Physical health was affected by injuries, tendonitis, and kidney stones. Family, friends, and trusted adults were also consistently identified as sources of support. All of the participants were aware of campus counseling support available to them, yet none of them utilized the services. INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 28 To understand how participants perceived and experienced stress, it was essential to get a working definition of stress from each participant. Even though individuals experience stress differently, resoundingly, the participants definitions carried similar themes. The terms worry, anxiety, and overwhelmed surfaced frequently in the interviews. When discussing the feelings of worry, being overwhelmed, or anxiety, all the participants seemed to accept those feelings as a natural part of being a college student. Words such as draining and negative could illustrate the toll stress took in some participants lives. Some participants discussed how stress caused them to overthink or have racing thoughts, causing difficulties in their daily lives. Many of the participants needed time to consider their definition of stress. One participant summed up the definitions of stress by stating: (sighing and thinking) That's the tough one. Gosh. Um. Just like...feeling overwhelmed. I guess, not being able to handle those situations like presented to me? Um, in a more relaxed manner? Which was the time those situations are relaxed and I just overthink. I get stressed...and anxious about it (Participant F). Other participants with mental health diagnoses discussed how dealing with a mental health diagnosis, in addition to stress, led them to a feeling of burnout or a desire to avoid stress altogether. Lastly, many participants described stress's role concerning motivation to complete daily tasks. Two themes emerged from the interviews regarding participants experiences with perceptions of IA regarding stress and coping. Table 2 provides an overview of the themes, theme definitions, and sample quotes supporting the theme. Theme one, interoceptive awareness and experiences of stress, contained many sub-themes relating to IA: 1) the physiological effects of stress, 2) the effects of stress on eating behaviors and levels of arousal, INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 29 3) the interpretation and the impact of stress on daily life, and 4) ways participants know they are no longer experiencing stress. Theme two, coping strategies covers helpful and not helpful means of managing stress. Figure 1 depicts the connection between all the themes. Interoceptive Awareness and Experiences of Stress The central theme of IA and experiences of stress emerged due to the participants descriptions of their experiences with stress. The participants were asked about their perceptions and interpretations of stress in the interview to understand their IA and awareness of stress in their bodies. Perception of stress refers to the physiological IA sensations within the body, such as heart rate, temperature, hunger, tiredness, and toileting needs. IA also requires an individual to adequately interpret those physiological sensations and respond accordingly. The participants mainly described stress as acute physiological sensations and a cognitive experience. Some words used to describe being aware of feeling stressed included feeling heightened stress, feeling overwhelmed, and feeling awkward. Participants reported feeling like they were doing too much, overthinking things, and catastrophizing situations. Together, perception and interpretation of IA became the experience of stress in coding for themes. Participants were asked to describe how they experienced stress in their bodies. While participants could identify bodily sensations related to IA, such as heart rate, an increase in temperature, and a nervous stomach, most were only aware of the term IA after receiving the educational handout (Appendix C). The handout described how IA affects a person, such as social participation, emotional regulation, and bodily sensations concerning stress. Once the participants understood that IA encompassed the sensations of hunger, tiredness, boredom, toileting needs, and mood, they could use a more detailed description of how they experienced stress. Two of the participants were surprised and appeared excited to learn INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 30 about IA. Participant F exclaimed, Whoa, okay! (taking a flyer and looking interested by sitting forward in the chair)," and Participant G stated, I was looking at it, like, (loud exclamation) Oh, these are what this means! Some participants were surprised at the connection between physiological IA and their reactions during stress. Participant H simply stated, Crying. Sleeping. Eating. After reading the handout, the participants understood that IA affected social participation and emotional regulation and could speak to the ways stress impacted their moods. When discussing mood, most participants noted they became more easily annoyed, withdrawn, and irritable with others. Participants described not being able to handle social situations, handle coursework, or focus in class when experiencing stress. Participants would spend less time in social situations with friends or roommates in times of stress. Participant F reported, Oh, little problems start to be, like, way bigger. Participant H stated she asked her roommates to leave her alone. Some participants reported never experiencing a time when they were not feeling stressed, and it was difficult to notice how their bodies felt when no longer stressed. Several participants explained having a baseline of stress that felt constant and integrated into their daily lives. Participant B defined stress from personal experience, "I mean, like, the more technical definition would be, like, undo worry, but I've just been doing stress for a while. So. It's just part of life for me (very matter of fact in tone). The participants frequently described physiological sensations related to heart rate, temperature, hunger, and sleepiness. Sub-themes related to the impact of stress on hunger and arousal levels related to the experience of stress focused on how participants noticed these IA signals when stressed. The participants diverged significantly when describing how stress INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 31 affected hunger and sleep, as well as how they responded to their personal physiological IA regarding stress. The Physiological Sensations Related to the Experience of Stress The following terms were the most used to describe the experience of stress in the body: being alert, increased heart rate, hunger, loss of appetite, restlessness, tension, sore muscles, thirst, tired, tremor, increased startle reflex, physically hot, nervous stomach, lightheaded, sweating, and mood swings. A few participants focused on the physical feelings associated with stress. Participant A was able to identify how she feels nervous, Like...I'll get like butterflies in my stomach...or... like, be sweating or things like that. (moving hands to show emphasis)." Along with sweating, another participant described becoming physically hot (Participant B). A racing or pounding heart was also a descriptor Participant D used to describe her experience: I get really sweaty. Or...I. I feel, like, racing thoughts as well as, like, a...an increased heart rateIt's, for a lack of a better term, like, I can feel my heart kind of pounding, and I'm sweaty, and I'm just kind of, like, jittery. Participant H also noted a racing heart, "My hands will shake...And I have a heart condition (looking serious and bringing hands to heart)So, my heart beats really fast. But like...when I'm stressed...like, my resting heart rate gets faster." Participants A and E noticed restlessness and a need to move. Muscle tension in the neck and back was also noted, I guess I maybe I get a little bit tense, like, my muscles might get a bit tense (Participant C). Impact of Stress on Appetite, Eating Behaviors, and Levels of Arousal The experience of hunger became a source of divergence among participants. Some participants noticed the sensation of hunger more acutely and engaged in stress eating. Others did not notice their hunger sensations at all. The IA of hunger, or lack thereof, impacted the INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 32 eating behaviors of the participants. Some participants connected their IA of hunger to their stress levels and noticed that their IA of hunger returned to normal when they no longer experienced stress. A few of the participants did not correlate their IA experience with hunger to stress at all. Participant C described her experience the following way: Well, definitely...So, it's kind of, like, a hit or miss. Like, sometimes if I'm stressed, I'm hungry. Other times, it's I have no appetite at all. Um, So... I don't really know, like, what's the difference, like, what causes the difference between, but sometimes it's, like, either one of those. Participant H drew attention to her appetite regarding stress, "Um, ah...But I eat a lot (stressing a lot) when I'm stressed." Many discussed eating because they were stressed and not because they were hungry. Participant D summed up her IA of hunger when experiencing stress by making this observation: I would say more, like, not physiological, but more psychological feelings. Like, Oh I'm guilty because I ate something even though I'm not hungry. Like, I couldn't control my psychological, like, appetite instead of actual hunger or drive for hunger. Participants noticed they would feel bad after overeating, using words like guilty or gross. When overeating, participants noticed cravings for certain foods, such as sweet or salty snacks, versus eating healthy foods. Participant C noted: (Smiling and thinking) I guess, they'll just be...like...I'm gonna stress eatIm just gonna eat this box of goldfish, that's my thing sometimes. P1: And does that...so, with the stress eating, do you notice your level of fullness at all or? PC: Yeah, and I usually regret it instantly (smiling and nodding). P1: Okay. So is it just, like, eat...eat and then all of the sudden...? PC: Like, I'll pour myself like a bowl of Goldfish or something and then I'll be, INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 33 like, you really...and then finish it and then go, You really didn't need to eat that. And so, then Im just, like, it's not, like, I just give up. It's not like I'm guilty (stressing the word guilty) of eating, like, feel guilt of eating it. It's just that I'm like, I'm like, you just ate that and you weren't even really hungry. So, like... Participants who overlooked their IA of hunger often required outside cueing from others to eat. Those with family members on campus noticed mood changes and asked participants if they had eaten. Some roommates provided the cues by reminding the participant the cafeteria was closing soon. Participant D went on to discuss how her decreased IA concerning hunger required outside interventions to remind her to eat: Yes, usually, usually, like, when Ive been studying or, like, my roommate is studying, it's usually one of our suitemates that comes into our room and is like, Hey, do you guys want to go to dinner? Like, it's almost time for it to close in the cafeteria or something like that. And we'd be like, Oh, like look at the time, and then Some participants noticed they were hungry at times but not at other times when experiencing stress. Participant H demonstrated the most varied personal experiences with hunger: Yeah, like, I'm starving all the time. Like, theres days...which that's actually really interesting because there's days where I'm, like, I cannot get enough to eat, where, like, I'm (stressing the next few words) constantly starving. So, I wonder if I was stressed out in those days. That's interesting. But yeah, hunger definitely increases. I, like, inhaled six wings, fries, and, like, a whole salmon filet in, like, 30 minutes one day, and I was, like, What is my problem? (looking back at handout) Like, full. Like, what does that mean? P1: Being aware that you're feeling full, like, after you've eaten? PH: Oh, I can't talk on that. I have a lot of stomach problems. So, I will eat two bites of food, and I will INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 34 feel full, and I had to keep forcing myself to eat because I know that my body needs more food. The participants also noted how their moods were affected by overeating or not eating. Some participants became dysregulated after not eating, i.e., stating they were grumpy or hangry, or felt guilt after overeating. Chapter 5 will explore the relationship between IA and emotional regulation more in-depth regarding the literature. Once students understood the full scope of what IA encompassed, the feeling of tiredness appeared in their discussions. However, their IA of tiredness varied among them. Many of the participants noted their sleeping habits were affected by stress. Some participants felt more tired when experiencing stress, while others felt more alert. Participants who noticed they became more alert focused on how this causes feelings of anxiety, wariness, and stress. Participant A focused on the ways stress increased alertness by stating, I definitely feel, like, anxiety. It's, like, take oneumlike, racing heart rate. P1: Thank you forPA: Um, yeahI feel, like, not really tiredness (sounding thoughtful) more like, being awake Participant C stated, I feel like my alertness is actually better when I'm stressed. Ah. And I'm usually not calm. I'm usually pretty, like, I guess I'm maybe I'm a little anxious when I'm stressed and stuff, but Participant G acknowledged the connection between heart rate and feeling more alert, Um. I try to be alert. I'll say one when my heart rates up, I'm usually alert (laughing)." Participant G summed up her experience by stating, I think I'm least stressed when I'm less alert. Many of the participants connected stress to the physical sensation of feeling tired. A few participants connected the IA of feeling tired to studying and boredom. When asked about managing stress, Participant F stated, Um, I kind of sleep (big smile and soft laugh). Participant C described struggles with her sleep cycle: INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 35 Umm, a little bit. I do find myself like more...like, I like to go to bed early, but when I'm stressed, I tend to then stay up later and then, like, I just feel like I become...by the end of the week, if I'm really stressed, I just feel like exhausted and just, like, want to have no motivation to do anything. Sleep also interfered with class attendance, as one participant noted if he did not get 8 hours of sleep, he would miss a class. Participant C stated, I guess I usually just feel pretty tired then. That's the other, like, physical thing is that I just, like, feel like tired by the end of the day." Participant F noticed how being tired affected his focus and attention: I definitely get, like, tired. I will say I noticed. I don't know if this is, like, a physical or like a mental, but, like, if I'm really stressed about something, and I haven't had time to, like, think it through or, like, identify the issues, I'll have a hard time focusing. Participant D spoke on how she tries to manage the tired feelings while studying: Um, I know that I do kind of feel more tired when I am stressed, especially because, like, I associate stress with, like, a lot of studying or exams or anything like that. So, as well as boredom. Like, sometimes I'm just, like, I don't want to study anymore. I've studied for so long. I'm just, like, if I know it, I know it, if I don't, I don't. So I'm just, like, I'm trying to, like, encourage myself as well as, like, friends of mine to take breaks. And be, like, Hey, you deserve something, like, something you enjoy (stressing the word enjoy) after working so hard doing this. So it's kind of, like, a, a give and take almost relationship. Participant G simply expressed how being tired affects focus, (looking at the paper) Tiredness? 100 percent. All the time. I'm always tired. Um. Focus. Especially if I'm tired. One participant observed that sleep is not out of tiredness but out of avoidance, Cause it's just, like, it's not I'm tired, and I wanna go to sleep. It'sI just don't wanna be awake (slight INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 36 shake of the head)" (Participant B). He went on to discuss his desire to sleep when under stress as a means of avoiding the stress: When I get stressed, I shut down (cocking head to the right and slumping in the chair to indicate a tired or defeated posture). P1:Like, going into that like overwhelm (moving hands to indicate a wide space)? PB: Yeah, that's just it. Like, sometimes the solution is, I feel so bad I'm just gonna go to sleep (using a tone that indicates being aware of how bad things are). The participants could identify increased heart rate, nervous stomach, and sweat as the main bodily sensations when experiencing stress. Most participants were not aware of the ways hunger, levels of arousal, and mood related to IA. Not being able to interpret the personal physiological sensations of IA adequately led some participants to have trouble completing their daily activities. Experience of Stress and the Impact of Stress on Daily Life Even though IA relates to physiological sensations, IA requires individuals to notice the physiological sensations and act accordingly. Many participants used terms to describe the outward expression of the perception rather than identifying the physical sensation attached. Common terms to describe their stress were getting inside their head too much, isolating, overthinking, hyper-focus, shutting down, no motivation, and feeling self-conscious. Awareness of mood, such as grumpy or annoyed, also came into the descriptions. Participant A started by saying, "Yeah, and if its likemy mind keeps coming back to it. Like, I can't get it off my mind (slower, lower voice and stressing this point)." Participant C also noticed hyper-focus: INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 37 So when I feel start feeling stressed, I kind of just shut down, and I become very zoned in on, like, the things that I have to accomplish (stressing I have to accomplish) and I don't necessarily take a step back, back to, like, refocus. The effects of stress on mood were noticed, with Participant C getting crabby and Participant E noticing a change in behaviors related to her mood: I kinda just feel a little bit different. Like, I'm usually a very bubbly, talkative kind of, like, person like that (talking with hands and moving upper body in a relaxed way). And so, like, I know when I'm stressed, like, I don't talk as much. I kind of just. I almost, like, sometimes get a little annoyed when people try to, like, converse with me. P1: OKAY. PE: And so it's a lot of just like that social aspect kind of, like, disappears. Motivation. Motivation was an area that participants differentiated. Some participants noticed a lack of motivation while others became more motivated. Participant D made this observation: Um. I think stress, it depends on the situation, at least for me. Like, I know there are people who get stressed, and they sort of, like, shut down and they don't want to do anything or they become demotivated in any way. I can say for a number of situations I've had that as well. But I would say stress is also, like, a motivator for me as well. Participant C also noticed how stress can become a motivator, stating, But I guess, like, on the good side of stress is that...it drives me to...want to achieve something?" Participant E was able to identify how the lack of motivation is a cue to her being stressed: And then um, like, I'll, like, realize right away like that I just have, like, no motivation to do anything. Because again, I'm a very motivated person as well, like, I am very self- INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 38 motivated. And so, for me to, like, have the want to do nothing, that's when it kind of, like, you know it hits. Overall, the participants were able to identify how stress affected them, but they could expand upon their perceptions and interpretations of stress once they received the handout and explanation on IA. While the general experiences of stress did not change, participants were able to go deeper into their understanding and awareness of how stress affected them. Participant E noted, And just, like, everything's like at, like, the highest level it can be (nodding in awareness)." Participant F noted how the awareness contributes to his stress levels, "So, like, if I know that I'm stressed, does it change? Um... I feel like sometimes I get more stressed because I'm stressed, honestly. Participant G described what her IA experience was in relation to her diagnoses: So, so I would, so I think they happen (stressing the word happen), but I don't think I recognize them. I think I underestimate them, like, what you're saying, because I think for me. Especially since I've had, like, a history of anxiety and depression, I feel like these have been just all of these symptoms, I feel like, are just a constant for me. But it's, like, Oh! You know? Like, they happen. It's like, you know, we just gotta live with it. Habits and Routines. Participants discussed the ways stress affected their daily habits and routines. Some participants noticed how their activities of daily living (ADLs) and instrumental activities of daily living (IADLs) would suffer due to stress. Participant G stated, Just trying to take care of myself, like, for me with depression, anxiety, just brushing my teeth was a struggle enough, so just doing that goes back to self-care for me. Brushing my hair. Participants E and H noticed how their laundry became harder to manage when stressed. Participant B described how the stress of not being late to class affects his ADLs: INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 39 Um... Somewhat? I know in, like, in order to not be late...like, I will always leave early so I'm not late. Um, if I have to get up early for, like, a class, I will prioritize getting to class on time rather than, like...ah, like, taking a shower or brushing my teeth. Participant F observed he would miss class due to stress, Oh, I definitely missed class, just due to stress. I did not even go to practice one time just due to stress. The effects of stress on habits and routines can be detrimental to academic performance. Missing classes or not turning in assignments affects grades and overall GPA. The participants were able to identify how college life affected their stress levels and explore how their coping strategies helped or hindered them. Interoceptive Awareness When No Longer Experiencing Stress Participants were asked how they knew they were no longer stressed. Many responses focused on words like relaxed and calm, but specific IA sensations were not always immediately identified. Only a few participants were able to make the connection, such as Participant A, who stated: Like, I don't have that sweating or need to, like, move, and you know, I don't have that racing heart rate. I just feel like, calm (moving hands in a calming gesture). Like, I'm able to focus on things. P1: Yes. Don't need to move.talk about that a little bit more. PA: UmI guess that kind of goes with, like, focus. Like, just able towork on whatever I'm doing or, you knowstill in class or (looking thoughtful). Participant A went on to state, "Yeah, umI thinkjustlike, normallike, I don't notice any of those things. Like, I'm able to sleep at night. Like, yeah, um. Im just more comfortable, I guess, in my body." Participants mainly attributed this feeling of normal to a normal heart rate. INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 40 A few participants demonstrated difficulty identifying how they know they no longer feel stressed. The participants could identify feeling calm, without worry, and at ease but not precisely describe how that felt in their bodies. Participant C attempted to describe it the following way: I just feel like, like, a weights been lifted off my shoulders, like, I just feel very, like, calm. P1: What does calm feel like in your body? PC: Ah... (long and thoughtful pause, looking around the room in thought) P1: Or maybe this...oh well, Ill let you think on it. PC: Oh, it kind of...I honestly can't really put into words, like, what it would, what it feels like. Like. Umm... (continuing to look thoughtful). With the assistance of the handout to understand the connection between IA and physiological sensations, some participants could identify when they were no longer stressed. Participants with this awareness reported their IA was easier to understand. Participant C focused specifically on how feeling tired and hungry are experienced differently: Oh, I'd just, I definitely am not really then, tired. Um...like, I, I wanna go do something fun then, usually. And then I guess, like, I'm usually. I know that I'm not, like, stress eating, like. P1: Okay. PC: That's...it's, like, a normal hunger? P1: Yeah. PC: It's, like, Im not that... I'm just gonna sit here and eat this because I'm, like, trying to crank out like a paper. Once participants became more aware of the sensations involved with IA, they could speak deeper into their lived experiences. This transferred into the participants being able to speak on the second theme, which is coping strategies. Coping strategies covers helpful and not helpful means of managing stress. For the purpose of this research study, helpful coping strategies focus on things the participant did that allowed them to relieve stress in a healthy INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 41 way, such as paying attention to their bodily needs, reaching out to others, and engaging in selfcare. Not helpful coping strategies refers to something the participant did to escape or avoid stress that became detrimental to them, such as overeating or oversleeping, substance use, and nonsuicidal self-harm. Coping Strategies The coping strategies participants identified ranged from exploring stress from a topdown perspective to utilizing IA through sensory tools, sleep, and food. Participants noted that using food or sleep can be a healthy form of self-care or a destructive form of escape. All participants identified a support system consisting mainly of family and friends. For many of the participants, their mother was the number one source of support, and they would call her as a means of coping with stress. Helpful Coping Strategies The helpful coping strategies mentioned by the participants focused on support systems, self-care, sensory input, movement, and healthy distraction. Seeking out the support systems emerged as participants calling family members or spending time with friends. Many participants appeared visibly happy when discussing their helpful coping strategies, as demonstrated by smiles and stating the strategy made them feel relaxed. Participant G noted, I will say self-care is something I do. Participant G and Participant H commented in the interviews that self-care can be difficult when depressed. Participants noted that using healthy coping strategies helped them feel more in control or out of their heads when stressed. Participant E demonstrated this while discussing her use of fidgets and spa days to help with stress, stating: (Deep breath while thinking and looking around) Um...with both of them, I think it's kind of feeling just... like, I'm able to control everything (voice going up). Like, especially INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 42 with the fidgets, like, being able to just, like, kind of sit there, like, gets everything out, and then I'm just like, Okay. I can move it at my own pace. Focusing on movement and healthy distraction, many participants sought movement as a way to keep their minds off of the stressors. Television, reading, and music were the most common ways to distract the mind. Yoga, walking, and sports were other common ways to engage in movement. Participant D discussed engaging in many of these activities as a coping strategy, I go to the gym quite often. Um, I like exercising. Mainly. I like lifting more so than cardio, but I do both. Um, I talked to my family. Watch TV sometimes I read. Many of the participants identified therapy as helpful in their stress management. Participant G identified medication and therapy (nodding and sounding grateful) as key to her coping strategies. The discussion on coping strategies demonstrated how the participants were able to identify how some coping strategies can be good in small amounts but damaging if done excessively, as well as how some coping strategies do not work for every person. Not Helpful Coping Strategies While some participants identified many helpful strategies, some participants experienced the opposite. Sleep became a common thread among the interviews as a means of avoidance. Many participants noted they ate as a coping mechanism, not out of the physiological sensation of hunger. Some coping mechanisms that were named as helpful coping strategies by participants, like professional help or relaxation techniques, created the opposite effect for other participants. Some participants reacted negatively to medications and therapy. Participant B remarked, Yes! If I hear (counting down on fingers) yoga, a planner, meditation, or journaling one more time? I swear to God. (sounding exasperated, smiling and shaking head and looking down). Participant F did not find meditation useful for him during high stress. INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 43 Other participants remarked that they felt less stress when feeling less alert, seeking coping strategies to reduce their arousal levels. Participant G posited this could be the reason some college students engage in substance use: Drug usage is a thing...that a lot of college students use to escape...a lot of these symptoms that I feel, like, we have constantly. So... P1: What would you, like,...is that part of your routine, or is it? PG: It is, uh, something I engage inEvery now and then... uh...weed (saying weed in a matter-of-fact tone) P1: Okay, I was assuming, but I didn't wanna...like...PG: (smiling and laughing slightly while scrunching up shoulder and face) It feels weird to talk about, you know what I'm saying? (nodding) But yeah, it is something I think a lot of us do just to, like, take away from all of these symptoms that I feel like we do. And also, I think it's a part of escaping the alertness aspect as well. Just recognizing that you're not just thinking out there. Participant H also discussed using substances for coping, Being a 22-year-old, I dabble in drinking. She went on to explain it more: That helps. I mean, like, it's, like... (pausing to think about it) I don't know...I dont know if it helps, but it's just like. You know? Sometimes, you just need a drink (shrugging shoulders). I'm, like, I just need a drink, and then I'm, like, Okay, let's go (snapping fingers then pointing ahead with both arms up and smiling). I just need a break. Like, sometimes I just need a hard mental reset...(pausing to think). A few participants discussed self-harm, explicitly cutting on self or chewing on the skin around the nails. Participant G described it as Umm, okay, so, like, a few years ago. Depression, anxiety, self-harmThat was something I had done. P1: What did you do when you're self-harming? PG: I think it was. INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 44 So, I, Ive cut myselfBut I don't remember if it was or not, but chewing on my skin, apparently around my fingernails, is self-harm? And I didn't realize that. I think that was more for me, a habit. The coping strategies participants named mainly focused on taking their minds off the stressor or finding a way to get out of their heads. Many of the participants were unable to specifically identify how they felt or their IA after they engaged in coping strategies, similar to their inability to determine when they were no longer experiencing stress. The primary themes regarding the interoceptive awareness and experiences of stress and coping strategies demonstrated many similarities and differences that highlight the personal experiences of the participants. The participants all reported a similar understanding of what stress was and what events in their college experience contributed to their stress. The participants had some knowledge of what IA was but not the full scope of what IA encompassed. Information on IA provided in the interviews allowed participants to explore their stress experiences more deeply. Coping strategies unanimously included talking to family and friends. Many of the coping strategies directly related to personal IA experiences, but the participants were not always aware of this connection. How college students perceive personal IA regarding stress and coping in conjunction with the literature will be further discussed in the following section. Discussion This interpretive phenomenological study endeavored to understand whether undergraduate college students aged 18-24 who live on campus use IA to identify when they experience stress and engage in chosen coping strategies. The first research question focused on the personal IA of undergraduate college students, looking at how they perceive and interpret INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 45 their personal physiological sensations when experiencing stress. The second research question shifted to exploring personal IA's role when using preferred coping strategies. The summaries of the interviews (Appendix F) revealed how vast the IA experience was for the participants. The researcher provided participants with information on the concept of IA, as no one knew of the term. The content on the handout was based on extensive research on IA conducted by a national expert (Mahler, 2023). Participants could recognize personal physiological sensations of IA after receiving a handout explaining the basis of interoception and IA. The results demonstrated that the information on the handout helped the participants explore physiological IA sensations when experiencing stress and engaging in chosen coping strategies beyond just heart rate and feeling anxious. The participants appeared more thoughtful when discussing their lived experience of stress and their physiological IA. Most participants could differentiate when they experienced stress in their bodies versus no longer feeling stressed. Personal Interoceptive Awareness When Experiencing Stress Craig (2002) explained how the bodys ability to check in with its physiological state is the basis for how humans experience emotions. Craig (2002) also stated that IA allowed the brain to determine emotional states based on what the physical body was experiencing. IA cues come from the cardiovascular, pulmonary, gastrointestinal, genitourinary, nociceptive, chemosensory, osmotic, thermoregulatory, visceral, immune, and autonomic systems (Khalsa et al., 2018, p. 501). Optimal physiological interoceptive awareness allows a person to become aware and process hunger, pain, toileting needs, arousal levels, heart rate, and emotional status (Arora et al., 2021). Emotional regulation relies on the bodys ability to interpret IA and respond appropriately (Arora et al., 2021; Craig, 2002; Critchley & Garfinkel, 2017; Khalsa et al., 2018; Mahler, 2023; Nord & Garfinkel, 2022; Pinna & Edwards, 2020). Nord and Garfinkel (2022) INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 46 noted that an individuals ability to perceive and interpret their IA signals accurately affects the emotional response. The brain appraises the signals received from the body and then elicits an emotional response or reaction. The researchers stated that the same IA signal could be experienced very differently among individuals (2022). Schuette et al. (2020) discussed the connection between poor emotional regulation and poor IA. The researchers also noted a correlation between IA and adaptive coping behaviors (2020). Schmitt and Schoen (2022) supported the integration of IA into quality-of-life research by stating interoception was an essential dimension of health. The authors state that adequate IA supports individuals' ability to trust their feelings and promotes a sense of security. Thus, promoting IA enhances an individuals sense of safety and security (2022). An elevated heartbeat, changes in breathing patterns, flushed skin, sweating, and piloerection are all observable interoceptive signs (Khalsa et al., 2018, p. 502). The fact these sensations are observable with a starting and ending point could be why they were the initial physiological sensations reported by the participants associated with stress. Additionally, a normal heartbeat and feeling more at ease were some ways participants could identify no longer feeling stressed. However, the concept of IA expands beyond heart rate to everyday experiences such as hunger, tiredness, pain, toileting needs, focus, and boredom (Arora et al., 2021; Craig, 2002; Critchley & Garfinkel, 2017; Khalsa et al., 2018; Mahler, 2023; Nord & Garfinkel, 2022; Pinna & Edwards, 2020; Schuette et al., 2020; Stevenson et al., 2023). By opening the experience of IA and stress to more than the immediate and observable sensations, participants began to explore their experience of stress and IA on a broader spectrum. The participants began to explore how IA also affected their cognition, focus, emotional regulation, self-care, and social participation when presented with the handout (Mahler, 2023). INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 47 The results of this research study indicated that stress affected the participants IA, particularly in hunger and arousal. Stevenson et al. (2023) researched hunger in relation to IA and discovered wide variations in how individuals experience hunger. The researchers noted that the experience of hunger could be from the influence of an outside food that is desirable to eat, a desire or awareness of the need to eat, or the temporal aspect of when to eat (2023). One group of participants in this research study reported not feeling or not noticing hunger when feeling stressed. Many noticed someone else frequently reminded them to eat while studying because they were not taking regular breaks to eat. Not experiencing hunger during times of stress means participants were either not using IA to notice the physical sensations of hunger, internal cues, or they were not aware of the passage of time since last eating, external cues. On the other hand, several participants reported stress eating, or eating when not physically experiencing hunger. Stevenson et al. (2023) determined that the variations in hunger with IA warrant further research to determine what IA cues each individual is attributing to hunger, especially in areas related to uncontrolled eating. Quigley et al. (2021) determined that adequate IA and multisensory integration were necessary for eating. Another sub-theme that emerged from the interviews related to participant arousal levels when experiencing stress. While Arora et al. (2021) acknowledged a need for more research around sleep and IA, the researchers noted connections between poor sleep, overeating, and emotional dysregulation. According to Boke et al. (2019), higher stress rates were directly related to poor sleep. For some individuals, one of the IA signals associated with stress includes increased heart rate, which is also linked to poor sleep (Arora et al., 2021). Many of the participants noticed they felt more alert when experiencing stress, which contributed to poor sleep and feeling anxious. In addition to poor sleep, the participants felt more exhausted and less INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 48 engaged in daily activities. Participants noted that they would miss class or activities due to not sleeping well or feeling tired. This is consistent with students struggling to stay caught up in class. Equally important to understanding how IA connects to the awareness of stress is how IA helps identify when an individual is no longer feeling stressed. The word normal was frequently used when discussing no longer feeling stressed. The participants who understood their perceptions of their personal IA could describe the experience of being no longer stressed. They noted their heart rates decreased, sleep improved, and they would eat because they were hungry, not because they were experiencing stress. Some participants could recognize feeling less restless and could focus in class when not under stress, consistent with research identifying a connection between stress and ability to perform in school (Bistricky et al., 2020; Boke et al., 2019). All participants noted an improvement in emotional regulation when not experiencing stress, consistent with the literature (Craig, 2002; Critchley & Garfinkel, 2017; Khalsa et al., 2018; Mahler, 2023; Nord & Garfinkel, 2022; Pinna & Edwards, 2020). Being able to describe stress in terms broader than heart rate, flushed skin, and feeling anxious demonstrated how the participants understood how IA affected their lives after the immediate observable sensations. Recognizing their personal stress reactions through IA led participants to discuss how they knew when they were experiencing stress and when they were no longer stressed. Most of the participants identified coping strategies they used to help decrease stress. Although the participants discussed similar coping strategies, not everyone experienced the same outcomes. Individuals seek out coping mechanisms that provide a sense of relief. However, many are not aware of the connection between coping and IA. Role of Personal Interoceptive Awareness in Preferred Coping Strategies INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 49 The coping process requires constant appraisal between internal and external environments to determine if enough resources are available to manage the demands of the situation (Folkman et al., 1986; Straud & McNaughton-Cassill, 2019). Similar to the process of coping, several researchers noted IA requires the constant internal appraisal of bodily sensations to determine the most appropriate emotional state (Arora et al., 2021; Craig, 2002; Critchley & Garfinkel, 2017; Farb et al, 2015; Khalsa et al., 2017; Mahler, 2023; Nord & Garfinkel, 2022; Pinna & Edwards, 2020). The body is in a constant process to achieve homeostasis (Arora et al., 2021; Folkman et al., 1986; Khalsa et al., 2018; Spira, 2019). Recognizing IA signals can help determine the necessary interventions to achieve homeostasis (Spira, 2019). Being able to interpret personal IA accurately helps individuals understand what is happening in their bodies and respond accordingly (Schuette et al., 2020). However, the researchers noted IA might not consistently lead to healthy coping strategies (2020). Rodriguez & Provident (2018) conducted a study that provided evidence supporting that college students may not have adequately acquired skills to cope with the stressors they face. The researchers discovered that when college students' awareness of coping strategies increased, their ability to engage in them increased (2018). The more social support and connections an individual can access, the resilience and ability to manage stress increase (Sapadin & Hollander, 2021). Adolfi et al. (2017) reported the link between IA, emotion, and social cognition. In this research, the participants noticed they could engage in more social activities and felt more like themselves after reducing stress. Activities that promote calm inherently reduce heart rate and respirations, two components of IA that are most noticeable (Khalsa et al., 2018). According to Spira (2019), the body and brain will create a map with IA cues to achieve homeostasis. With repeated successes at achieving homeostasis, the brain will use the map to guide future situations (2019). Participants who INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 50 continually returned to helpful coping strategies utilized their IA maps to reduce stress appropriately. Schuette et al. (2020) suggested distraction could also decrease personal IA associated with stress, which affects emotional regulation and the ability to trust IA. Participants in the research study also spoke of ways of coping that were not helpful or harmful to them. Participants reported sleep, social media, or binging a television program became an escape to avoid thinking about the stressors. The participants admitted these coping strategies only worked temporarily and might lead to more stress. Substance use has been a common means of coping with stressors among college students as a means of escape and avoidance (Boke et al., 2019; Pedrelli et al., 2015). Paulas and Stewart (2014) proposed the concept that IA and substance use were connected in that the individual was using the substance to either enhance or decrease their physiological state. The authors discussed how this would be evident in the use of depressants to decrease arousal or stimulants to increase arousal (2014). As previously discussed, the avoidance of stress includes the dulling of the physiological IA signals associated with stress. The decrease of arousal with alcohol also dulls IA (Paulas & Stewart, 2014). Another means of distraction was nonsuicidal self-harm. Young et al. (2021) studied the connection between nonsuicidal self-harm and IA. The researchers proposed the behaviors were due to decreased IA but admit more research is needed to understand the breadth fully. The researchers also reported participants in their study who engaged in nonsuicidal self-harm found tracking their heart rate an uncomfortable experience (2021). Since pain is a component of IA (Craig, 2002; Critchley & Garfinkel, 2017; Khalsa et al., 2018; Mahler, 2023; Nord & Garfinkel, 2022; Pinna & Edwards, 2020; Schuette et al., 2021), the participants engaging in nonsuicidal self-harm may be using the signal of pain to distract from other IA signals associated with stress. INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 51 IA is very personal and requires individuals to understand their own bodily interpretations (Arora et al., 2021; Craig, 2002; Critchley & Garfinkel, 2017; Farb et al, 2015; Khalsa et al., 2017; Mahler, 2023; Nord & Garfinkel, 2022; Pinna & Edwards, 2020). Helping individuals notice and then become aware of interoception can then lead to adequate and accurate IA maps to assist with coping (Schuette et al., 2020; Spira 2019). Using IA to recognize and manage emotions leads to an improved sense of self (Quigley et al., 2021; Schuette et al., 2020). Left unmanaged, stress can become a barrier to college students (Bistricky et al., 2018). Connecting IA to Undergraduate College Students Lived Experience with Stress The WHO defines stress as the bodys response to something physical, emotional, or psychological that requires action or attention from the person (WHO, 2021). Bistricky et al. (2018) identified everyday stressors for college students as finances, moving away from home, relationships, and coursework. Most, if not all, participants could identify ways in which the transition to college was stressful. The participants commonly had issues with roommates, friends, and resident advisors. Participants noted that transitioning from living at home to independent living caused stress. Learning to manage time and schedules and figuring out how to study effectively became barriers they did not expect. Boke et al. (2019) noted that students in courses with higher math and science requirements reported higher stress levels. Almost all participants took a course load of 16 credit hours or more, coinciding with the academic stress. More than half of the participants planned to start a post-undergraduate graduate program. The graduate programs listed were all healthcare-related fields, with coursework focusing on sciences, which is consistent with the research of Boke et al. (2019). Stress related to academics leads to greater stress levels and an increased likelihood of developing a mental health disorder (Boke et al., 2019; Yzer & Gilasevitch, 2019). Bistricky et INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 52 al. (2020) also discussed how stress affects college students. The researchers noted that diagnoses of depression and anxiety are on the rise, and living with them made it difficult for the students to function in daily life (Bistricky et al., 2020; Boke et al., 2019; Pedrelli et al., 2015; Yzer & Gilasevitch, 2019). Consistent with the literature, half of the participants self-reported diagnoses of depression, anxiety, and ADHD. Even though there was access to mental health services on campus, research showed many college students do not utilize the support provided on campus for mental health for a myriad of reasons (Amanvermez et al., 2021; Shi, 2019). Yzer and Gilasevitch (2019) noted that structural changes needed to be in place to allow students the time to practice self-care for stress management. OTPs work in a myriad of settings, with one being college campuses (Spencer et al., 2018). OTPs address the occupations of ADLs, IADLs, health management, rest and sleep, education, work, play, leisure, and social participation (AOTA, 2020). Stress impacts performance in all areas of occupation, but poor IA affects ADLs, IADLs, health management, sleep, education, and social participation, as noted in the results of this study. Quigley et al. (2021) reported how IA was integrated with homeostasis, hunger, memory, emotional regulation, and an overall sense of self. The occupation of health management includes coping strategies, monitoring changes in symptoms, and managing emotions (AOTA, 2020). Working with campus counseling centers, OTPs can assist students experiencing stress or at risk of developing mental health disorders in learning to improve IA and coping strategies to manage their stress. By acknowledging the importance of IA as a dimension of health (Schmitt & Schoen, 2022), OTPs can be an integral part of establishing a healthy campus (ACHA, 2020). OTPs can use their scope of practice in conjunction with knowledge of IA to assist college students with the transition and participation in college (Khalsa et al., 2018; Schmitt & Schoen, 2022; Spencer INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 53 et al., 2018). By staying occupation-focused, OTPs can support students in establishing routines to address eating and sleeping through IA (Khalsa et al., 2018; Spencer et al., 2018). Exploring the lived experience of stress from a cognitive perspective is consistent with the literature studying college students and stress management from a health behavior lens (Amanvermez et al., 2021; Bistricky et al., 2018; Boke et al., 2019;Yzer & Gilasevitch, 2019). Bringing the concept of IA to stress can bring agency to individuals in managing their stress. However, participants need to understand the concept of IA first. Overall, education on IA can help college students become more aware of their stress experience and subsequent coping strategies. Limitations This research was met with several limitations. While the participants could give a rich perspective of their lived experience of stress and interoceptive awareness, only eight participants responded to the recruitment flyers. A college setting with a more diverse population might have drawn a wider variety of participants and responses. The demographic sample was predominantly Caucasian and female, which limits the diversity and transferability of the study. A drawback of snowball sampling was demonstrated by the majority of participants being in the same course of study. Real World Implications Most research on mental health conditions focuses on the cognitive implications of stress and stress management, not the bodily sensations related to stress (Amanvermez et al., 2021; Bistricky et al., 2018; Boke et al., 2019; Nord & Garfinkel, 2022; Yzer & Gilasevitch, 2019). Nord and Garfinkel (2022) proposed mental health conditions be treated in relation to IA. Many researchers focusing on college students addressed health behaviors through the lens of health behavior theories (Amanvermez et al., 2021; Bistricky et al., 2018; Boke et al., 2019; Yzer & INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 54 Gilasevitch, 2019). While these theories are vital to research, they do not take into account the role of IA in the experience of stress or coping. Helping college students become more aware of their IA signals, college students can learn to notice their stress responses and improve their abilities to cope. More importantly, using personal IA to manage stress effectively could assist college students' overall health and wellbeing. Becoming attuned to IA helps the individual recognize how heart rate, awareness of hunger, and sleep patterns are influenced by stress. Better awareness of IA leads to better mood and emotional regulation. Using personal IA allows individuals to return to helpful coping strategies in times of stress. When students can manage their stress, they can attend classes, focus in the classroom, and are more likely to complete daily functional tasks. Occupational therapists can implement interventions that address IA as well as participation in daily occupations on college campuses. Future Research A large portion of research on personal IA focuses on the specific populations like people diagnosed with autism, depression, anxiety, and PTSD. This researcher excluded articles that used the diagnosis of autism as the focus population to explore how IA can be generalizable in a college setting. Expanding the research into different groups and populations can broaden the audience and knowledge base on IA, leading to more evidence-based practice interventions. Literature suggests further research in the areas of college students mental health and stress management, as well as the role of IA in stress management (Amanvermez et al., 2021; Arora et al., 2021; Nord & Garfinkel, 2022; Stevenson et al., 2023; Yzer & Gilasevitch, 2019). Arora et al. (2021) stated more research on IA could help improve understanding of the mind-body connection. INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 55 This researcher recommends future studies exploring the coping behaviors of participants post-interview. This study would have benefited from a follow-up survey that explored IA and any changes or adaptations participants made in response to their personal IA. A survey could help determine if education on ways IA could identify when a person is experiencing stress. Furthermore, the survey could also determine if being more attuned to personal IA improved coping strategies or not. Increased understanding and addressing IA in college students may positively influence retention rates and improve overall campus mental health. Conclusion The concept of interoception has been studied for decades but still needs to be understood more clearly by the general public (Craig, 2002). The basis of this research was to determine if undergraduate college students' personal IA impacted the experience of stress and chosen coping strategies. For the most part, the participants did not understand what the term IA meant or the impact of IA on their experience of stress and subsequent coping strategies. Education on IA, in general, can improve how individuals understand their bodily signals. Learning to interpret personal IA appropriately can improve stress management, coping strategies, social participation, emotional regulation, and academic performance. Improved IA and coping strategies can help college campuses improve students' overall health and wellness. OTPs are skilled practitioners with the education and abilities to assist students with IA and improved participation in daily life. Researchers Self-Reflection Statement The process of understanding the undergraduate college students lived experience of stress required the researcher to be mindful of biases that created the initial research topic. The researcher noticed many of the graduate students she was interacting with complained of increased stress and anxiety related to academics. The researcher was curious if environmental or INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 56 sensory input was contributing or increasing stress levels. As the researcher conducted more literature reviews into the topic, IA became more interesting as a research topic. Exploring the research of Dr. Kelly Mahler and her contributions to the field of occupational therapy and IA, it became clear to the researcher IA and college students experience of stress was a viable research topic. The researcher became curious about whether or not this population was aware of how interoception appeared when experiencing stress or choosing coping strategies. Trustworthiness was established through credibility, dependability, confirmability, transferability (Creswell & Poth, 2018; Henderson & Rheault, 2004; Marshall & Rossman, 2011). As someone who worked in the field of mental health and educated individuals on coping strategies, the researcher made sure to bracket any preconceived notions of what stress and coping mean to her. The researcher acknowledged the participants might engage in substance use but were more likely to engage in physical activity due to their chosen college majors. Being able to separate preconceived ideas allowed the researcher to focus on the lived experience of the participant. For credibility, the researcher listened to the recordings several times, initially marking recurring words or phrases in each individual interview. The researcher did not move on to the next interview until the essence and lived experience of each participant was noted and summarized. Another step to ensure credibility occurred through the researcher sending the transcripts and descriptive summaries to the participants. After reading the transcripts and summaries, none of the participants requested corrections. One participant even commented the summary was very accurate of her lived experience. Confirmability and credibility occurred through the researcher bracketing and taking detailed memos. A review of the initial coding for themes in the data by Dr. Kelly also addressed confirmability (Creswell & Poth, 2018). The committee members reviewed the results accurately INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 57 reflected the research questions and the participants' lived experiences. The process of coding for themes took time and effort from the researcher and the research committee. The concept of IA was very familiar to the studys content expert, but the researcher needed to make sure others not as familiar with the concept on the committee could also understand the themes associated with the study. The review and revision process not only allowed the researcher to describe the phenomenon the participants experienced accurately, but also allowed for the transferability of the study. Using the interview guide in future research at colleges and universities with similar demographic information could demonstrate the dependability of the research questions and lived experience of college students in regards to personal IA awareness with stress and coping. The researcher learned the concept of IA is very important to ones overall health, but not widely known or understood. Throughout this process, the researcher learned more about the importance of IA in identifying emotions and choosing coping strategies. The researcher hopes to continue to explore the concept of IA in order to understand the lived experiences of her students and improve the quality of life for college students. Human Subjects Statement The Institutional Review Board permitted the researcher to collect data in March 2023. The study was reviewed and approved as exempt. All participants were provided informed consent. 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Journal of American College Health, 67(2), 153160. https://doi.org/10.1080/07448481.2018.1462828 66 INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS Tables Table 1 Demographic Information on Participants Participant Gender identity Age Year in undergraduate study Ethnicity Degree path A Female 19 Sophomore Caucasian Working towards getting accepted to a DPT program B Male 22 Senior Caucasian Communications C Female 22 Senior Caucasian Exercise Science D Female 21 Junior Caucasian Exercise Science E Female 21 Senior Caucasian/ Latina Exercise Science + Human Performance and Fitness F Male 19 Freshman Caucasian Communications G Female 19 Freshman Caucasian Psychology & Sociology H Female 22 Senior Caucasian Human Performance and Fitness 67 INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 68 Table 2 Sample of Themes Emerging from the College Students Perceptions of Personal Interoceptive Awareness Regarding Stress and Coping Interviews Theme 1 Definition & Terms Used by Participants IA & How the interviewees identified knowing they Experience of were stressed and what was listed after being Stress given a handout defining interoceptive awareness. This includes IA, their interpretations, and perceptions of what they feel in their body in times of stress. Also included are sources of stress and how stress impacts habits and routines. Terms: anxiety, racing heart, more awake, more aware of what is going on, harder to think, boredom and tired with studying, sweating, don't notice hunger or the need to use the bathroom, feels burnout, not aware of them happening, hunger increases Example Quotes "(Nodding) Yeah, I definitely feel like anxiety. It's like take oneumlike, racing heart ratePA: Um, yeahI feel like not really tiredness (sounding thoughtful)more like being awakeand yeah(PA, page 8, lines 206210). I don't know if this is like a physical or like a mental, but like. If I'm really stressed about something and I haven't had time to like think it through or like identify the issues, I'll have a hard time focusing. So like in class,...practice. Like I'll still think about it like it'll like it could be like mid conversation with someone and I'm not like really listening. Like I'm listening enough to respond (pointing to ears and then towards the window for emphasis), but I'm thinking about the other thing and it's. It's terrible, I would say. Maybe a little more like grumpy, I guess (PF, pages 5-6, lines 113-121). Theme 1 Sub Themes Physiological Terms used to describe their experience of Experiences stress in their bodies. Terms: being alert, increased heart rate, hunger, loss of appetite, restlessness, tension, sore muscles, thirst, tired, tremor, increased startle reflex, I get really sweaty. Or...I. I feel, like, racing thoughts as well as, like, a...an increased heart rate It's, for a lack of a better term, like, I can feel my INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS physically hot, nervous stomach, lightheaded, sweating, mood swings 69 heart kind of pounding, and I'm sweaty, and I'm just kind of, like, jittery. (PD, page 5, lines 101-105) I definitely think I have upper back tension (moving hands towards upper back). For sure. And neck pain too, just from like sitting and just staring at a screen and doing things constantly. It's not(PG, page 7, lines 146-149). Um...I don't know about temperature. I feel like that would also have to kind of go with sweating, like probably like those two kind of go hand in hand. Ummm (thinking) Honestly, I don't really feel like I notice hunger or going to the bathroom at all. Like I just even if it is like a present situation...P1: OK. P42723: Like I just it's an ignored almost or it's like pushed to the back of my mind (PD, page 7, lines 124-127). Impact on Appetite and Eating Behaviors Ways in which participants described their appetite and eating habits when experiencing stress. Terms: grumpy, annoyed, "hangry," stress eating, not hungry, force to eat. Well, definitely...So, it's kind of, like, a hit or miss. Like, sometimes if I'm stressed, I'm hungry. Other times, it's I have no appetite at all. Um, So... I don't really know, like, what's the difference, like, what causes the difference between, but sometimes it's, like, either one of those. (PC, page 8, lines 181-185). "Um, I haven't tried it, like purposefully, but sometimes I do catch myself kind of stress INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 70 eating. (PD, page 8, lines 174180). Impact on Levels of Arousal Ways in which participants described their experiences with levels of arousal when stressed. Terms: stress zaps motivation, no motivation, more alert, baseline stressed all the time, stressed all the time, hard to sleep or sleep all the time. "Oh, I get. I definitely get like tired. (PF, page 5, line 113). "Everything just kind of gets, like, heightened almost. Because like as soon as you said like tired like I...I feel just like drained, like, but like both physically but also mentally (PE, page 7, lines 146-147). Uhhgg (making a sound in agreement and exasperation) Um, And then I get alert. Like I'm just kind of more wary of what's going on (PB, page 7, lines167-168). Impact on Daily Life Ways in which the experience of stress impacts participants daily life. Terms: skipping or missing class, delays with turning in assignments, not being able to stay organized or plan out school work, missing practices, poor social participation, quitting clubs or sport teams, poor ADL/IADLs "Um, So I guess like on the negative side of stress. It just makes me kind of like, I guess we could say crabby (being thoughtful then matter-of-fact and smiling). It just like, I just am very like I'm hard on myself. So when I feel start feeling stressed, I kind of just shut down and I become very zoned in on like the things that I have to accomplish (stressing I have to accomplish) (PC, pages 6-7, lines 143- 148) "Um, yes. I would say my motivation drops. Oh, I definitely missed class, just due to stress. I did not even go to practice one time just due to stress. (PF, page 6, lines 123124). No Longer Experiencing Stress How they are aware of no longer being stressed or their interoceptive awareness of not being stressed. Terms: feel relaxed, calm, Oh, I'd just I definitely am not really then tired. Um...Like I, I wanna go do something fun INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 71 normal, feels like a weight has been lifted, feel like being around others, more comfortable in body, don't feel the need to move, able to focus on things, always stressed so harder to know why not stressed, sleep is better, at ease, know when actually hungry, feeling motivated again, feel like getting stuff done, don't really know when no longer stressed, least stressed when less alert, normal hunger, heart rate is normal, IA cues are less intense, normal temperature then usually. And then I guess like I'm usually. I know that I'm not like, stress eating, likeThat's...it's like a normal hunger? It's like, Im not that... I'm just gonna sit here and eat this because I'm like, trying to crank out like a paper (PC, page 9, lines 197-203). "Definitely calm. Um...I would say heart rate, temperature probably back to normal. And then boredom, I would say kinda is the opposite. Like I, I want to do more things(PD, page 7, lines 150-152). "Yeah, exactly (smiling and nodding). I like, I definitely forget to eat sometimes because of that business and kind of balancing factor. But like it's easier to know that I have to eat or like that, like to remind myself instead of like someone reminding me when I'm like not stressed or something like that. (PE, page 7, lines 159-161). Theme 2 Definition & Terms Used by Participants Example Quotes Coping Strategies Anything the person engages in to relieve stress or relax Theme 2 Sub Themes Helpful Coping Strategies Anything that is adaptive or proactive in managing stress. Terms: Sensory, self-cares, friends, yoga, walking, running, lifting weights, swimming, television, reading, music, spa days, fidget use, showers, resting/sleep, prayer, journaling/devotional, pets, crying, therapy, medications. "Yeah. I think a big one is like, being with other people, like, my friendsjust to distract myselfto get out of my own head and, you know, go to target and go get dinner and you know, just like kind of distract myself. Listen to music. Really, just like INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 72 something else (stressing something else) other than just being alone with my thoughts. PA, page 9, lines 238-241)." I go to the gym quite often. Um, I like exercising. Mainly. I like lifting more so than cardio, but I do both. Um, I talked to my family. Watch TV sometimes I read (PD, page 7, lines 158-160). Not Helpful Coping Strategies Anything that is maladaptive or harmful to the participant. Terms: Substance use weed/EtOH, self-harm, cutting, nail biting/chewing, avoidance - tv, video games, sleep, stress eating, therapy, some medications. So I, Ive cut myselfBut, I don't remember if it was or not, but chewing on my skin, apparently around my fingernails is self-harm? And I didn't realize that. I think that was more for me, a habit (PG, page 14, lines 336-338). "Being a 22 year old, I dabble in drinking. (PH, page 9, line 211)." "Drug usage is a thing...that a lot of college students use to escape...a lot of these symptoms that I feel like we have constantlyIt is, uh, something I engage inEvery now and then... uh...weed (saying weed in a matter-offact tone) (PG, page 11, lines 250-260). INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS Figures Figure 1 Interoceptive Awareness in Regards to Stress and Coping 73 INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 74 Appendices Appendix A Informed Consent Document for Research Study Participation Title of Project: College Students Perception of Personal IA Regarding Stress and Coping For Research Conducted at: Research will be conducted to complete the degree requirements for a Doctor of Health Science degree through the University of Indianapolis. Principal Investigators: Dr. Jennifer Fogo: jfogo@uindy.edu Stephanie Phares: pharesstephaniel@sau.edu or pharess@uindy.edu WHAT IS THIS FORM? You are invited to participate in a research study. The purpose of this consent form is to describe the research study to help you decide if you want to participate. It also tells you about why the study is being done, about the risks and benefits of the study, and your rights as a research subject. You are being asked to participate because you are an undergraduate college student aged 18-24 living on campus and understand written and spoken English. You can choose if you want to be in the research study. If you wish, you can discuss it with other people before deciding. You should not feel pressured to participate. If you decide to participate in this research study, you will be asked to check the YES box on the form indicating informed consent and agreement to participate in this research study. You will be given a copy to keep. WHY IS THIS STUDY BEING DONE? INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 75 How a student chooses to cope with stress will affect their behaviors, emotions, relationships, physical well-being, and academic endeavors (Boke et al., 2019). Prior research has shown the link between IA and emotional regulation (Price & Hooven, 2018; Schmitt & Schoen, 2022). Consideration of the student stress experience is key in understanding their stress profile and subsequent treatment strategies (Boke et al., 2019). Without addressing IA, students may not realize they are under stress until they are overwhelmed and in academic distress, presenting as poor attendance, an inability to maintain an appropriate grade point average, or struggling to complete daily tasks. Current research addressing college students lived experience with stress does not explore the relationships between IA, stress management, and coping (Amanvermez et al., 2021; Bistricky et al., 2018; Boke et al., 2019; Rodriguez & Provident, 2018; Sapadin & Hollander, 2021; Shi, 2019; Straud & McNaughton-Cassill, 2019; Yzer & Gilasevitch, 2019). An opportunity exists to understand how IA influences stress and coping abilities in college students. WHAT IS THE PURPOSE OF THIS STUDY? This research aims to understand whether undergraduate college students aged 18-24 who live on campus use IA to identify when they experience stress and engage in chosen coping strategies. HOW MANY PEOPLE WILL PARTICIPATE? We anticipate that about eight to ten people will be invited to participate in this study. HOW LONG WILL I BE IN THIS STUDY? Participants will be asked to participate in one 45-minute interview session. WHAT WILL HAPPEN DURING THIS STUDY? INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 76 If you agree to participate in this study, you will be asked to participate in one interview and then read a summary of the data analysis upon completion of the analysis to ensure the information is an accurate reflection of your experience. WHAT ARE THE RISKS OF THIS STUDY? There are minimal psychological risks associated with this research due to the interview guide asking questions directly related to personal stress and coping. The research will not cause a level of either harm or discomfort to participants that is greater than what they encounter ordinarily in their daily lives. Participants will be given information regarding counseling services available to them on campus. WHAT ARE THE BENEFITS OF TAKING PART IN THIS STUDY? Students participating in the research study may benefit from understanding what IA is and how they can apply it to their personal lives. A deeper understanding of how to use IA can improve emotional regulation (Price & Hooven, 2018; Schmitt & Schoen, 2022). College campuses and student body populations may benefit in some way. By understanding students' perspectives on personal IA with stress and coping, college campuses can explore integrating IA into mental health interventions. Studying the link between IA and stress management in college students may have an impact on overall student wellness, academic performance, and coping strategies. Additionally, occupational therapy practitioners may expand services on college campuses to address students interoceptive needs. Thus improving college students stress management and overall quality of life. HOW WILL MY PERSONAL INFORMATION BE KEPT CONFIDENTIAL? We will do our best to keep your information as confidential as possible. We will not tell anyone you are in this study. Your name will not appear on any of the paper or electronic forms INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 77 that are used to collect data. All of your forms will be labeled with a code number and kept in a locked file cabinet in the Center for Health Sciences Education building behind a locked door. The same code will be used to label any computer files where your data are stored. In addition, all electronic data will be stored on a computer that is protected with a password. Only Stephanie Phares will have access to the information contained in your paper or electronic records. Information collected from you will be deleted or destroyed no later than December 2026. No information that would reveal your identity will be included in any publication or presentation resulting from this study. WHAT ARE THE COSTS OF BEING PART OF THIS STUDY? There is no cost to you for being in this research study. WILL I BE PAID FOR PARTICIPATING IN THIS STUDY? You will not be paid for being in this research study. WHAT IF I AM INJURED BECAUSE I TOOK PART IN THIS STUDY? Although I believe that the risk of being injured during the course of this study is minimal, if you are injured, notify Stephanie Phares immediately. We will call for medical assistance if you require medical care for your illness or injury. Any medical care that you receive will be billed to you or to your insurance company in the same manner as your other medical needs are addressed. Neither the investigators nor St. Ambrose University can assume responsibility for any additional medical costs you may incur due to your participation in this research. WHAT ARE MY RIGHTS IF I TAKE PART IN THIS STUDY? Taking part in this research study is completely voluntary. You do not have to be in the study if you do not want to. If you decide to be in this study, but later change your mind, you INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 78 may stop participating at any time. If you decide not to be in this study, or if you stop participating at any time, you will not be penalized or lose any benefits to which you are otherwise entitled. WHAT IF I HAVE QUESTIONS? We encourage you to ask questions and to take as much time as you need to make a decision. We will be happy to answer any questions you have about this study now or at any time during the study. If you have further questions about this study or a research-related problem, you may contact one of the principal investigators: Stephanie Phares: (563) 333-6083 or (563) 370-3706. pharesstephaniel@sau.edu or pharess@uindy.edu INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS Appendix B Recruitment Flyer 79 INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS Appendix C Information Sheet 80 INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS Appendix D Google Form 81 INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 82 Appendix E Interview Guide Hello, my name is Stephanie Phares, and I am currently a student at the University of Indianapolis working towards a Doctor of Health Science Degree. My dissertation research focuses on understanding how college students experience stress, cope with that stress, and explore the role occupational therapists may play in the college campus setting to assist students with that stress. This interview aims to hear your first-hand experiences as a college student with stress and to cope. I hope to understand the thoughts and feelings surrounding your experiences. With your permission, I would like to record this interview. I will use that recording to produce a transcript that will be sent to you to ensure all the information gathered is correct and accurate. You will have two opportunities to provide corrections and feedback. The first is following the initial transcription of the interview, and the second will be following the initial analysis of your transcript. You can make corrections and return the corrected materials to me. If you have questions throughout this process, please email me at pharesstephaniel@sau.edu. Once the dissertation process is complete, the interview recording will be deleted. Now that I have started the recording, I want to tell you what you can expect regarding how the information from this interview will be used. The information obtained will be confidential, and no identifying information will be used to report this research. The information will inform current services provided on campus for student mental health. The interview is expected to last about 30 minutes. This interview is voluntary, and you have the right to refuse to answer any questions asked, take breaks as needed, and you may terminate the interview at any time. Before asking questions from the interview guide, Id like to confirm the demographic INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS information you provided on the Google Form. Thank you, I appreciate your time and information. Interview Guide Questions 1. Tell me about your college experience so far. a. What has been the most rewarding part of college? b. What has been the most difficult part of college? 2. What is your definition of stress? 3. How does stress affect you? a. How does stress impact your habits and routines? 4. How do you become aware that you are stressed? a. What specific sensations do you notice when you are stressed? b. How does your body feel when you are stressed? 5. The following sensations refer to your interoceptive senses: tiredness, hunger, temperature, toileting needs, and heart rate. How do you experience these sensations when you are stressed? a. If you notice these sensations, how do they change in response to stress? 6. How do you know you are no longer feeling stressed? a. Earlier, you mentioned (x, y, z) is how you experience stress. How do those change to let you know you are no longer feeling stressed? b. How aware are you of your interoceptive needs when you are not stressed? 7. How do you deal with or manage your stress? a. What about that (x, y, z) helps you notice your stress decreasing or becoming more manageable? 83 INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS b. How does your body feel when you do those things? 8. Have you ever tried to do things to manage your stress that was not helpful? a. What let you know they were not helpful? b. How did your body feel when you did (x, y, z)? 9. What types of support do you have in place to manage stress? a. Who are the people that are helpful to you? b. How do your support systems help you manage your stress? c. When do you know you need to seek their support? 10. What supports do you wish you had more of to help you manage your stress? a. What is your understanding of campus support available to you? 11. Is there anything else you would like to tell me about your stress and coping strategies that would be helpful to this research? 84 INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 85 Appendix F Interview Descriptive Summaries A Participant A (PA) is a 19-year-old Caucasian female who is a sophomore working towards a Doctor of Physical Therapy degree at a mid-sized, private Midwest college. PA was initially nervous, slightly rocking back and forth in the chair. The interview began with the overall college experience, both difficult and rewarding experiences. PA began the interview by discussing the difficult decision to quit the cross-country team. PA spoke softly and looked down while discussing this initially but became more animated as the interview progressed. She expressed frustration with the coachs attitude and lack of empathy with PA becoming injured and a teammates mental health. She likened the experience of interacting with this person to an abusive relationship (personal communication, April 18, 2023, line 116). The interview's tone shifted when PA discussed the positive experience of mission trips with the campus ministry. Campus ministry offers PA spiritual guidance, opportunities for personal growth, and a base for friendships. Worry or anxiety about your life, things going on (personal communication, April 18, 2023, line 143) is the definition of stress that PA provided. Physiological sensations associated with stress include feeling nervous, anxious, butterflies in the stomach, racing heart rate, fidgeting, needing to move or not being able to sit still, poor sleep, and sweating. She tends to get into her head and isolate herself when stressed, as well as take on the stress of others. When no longer feeling stressed, she reports feeling calm and less of the aforementioned sensations (personal communication, April 18, 2023, lines 220-222). PA reports only sometimes being fully aware of how those sensations appear when stressed. Specific physiological IA when INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 86 stressed presents as not wanting to eat, having a racing heart rate, or not being able to sleep. She does notice a need to move her body when anxious, especially before a race. PA only realized she had a pre-race routine once her teammates made her aware of her behaviors (personal communication, April 18, 2023, lines 256-259). Additional coping strategies are listening to music, going shopping, going out to eat, and talking to friends, family, and her priest. She reports looking to get out of her head with positive distractions (personal communication, April 18, 2023, lines 236-239). Support and spiritual guidance are the biggest means of coping for her. A theme in discussing coping strategies is the top-down approach to being aware of stress in a more cognitive capacity. She focused more on how she will fixate on the stressor, catastrophize (line 272), and need to get out of her head. There was no connection between IA and the stress level experienced except with running or before a test. PA stated her nerves before a race could even make her throw up (personal communication, April 18, 2023, line 182). The overall essence of the interview focused on personal growth and the changes since starting college. The decision to quit the cross-country team, going on mission trips, and awareness of emotional maturity (personal communication, April 18, 2023, lines 261-262) have been cited as areas of huge growth in the last year (personal communication, April 18, 2023, lines 341-342). All in all, PA has enjoyed the college experience and has developed healthy coping strategies to manage her stress. Future suggestions for this study would be to ask participants to complete a survey to determine if they are more or less aware of their physiological interoceptive sensations when experiencing stress or during chosen coping strategies post-interview. INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 87 B Participant B (PB) is a 22-year-old Caucasian male who is a senior working towards a Communications degree at a mid-sized, private Midwest college. PB begins by expressing his frustration with the college that he will need to extend his credits into a fifth year of college due to the college eliminating theater as a major. This affected his credit load as a double major. He speaks slowly and chooses his words carefully. His tone of voice, body language, and facial expressions depict his frustration and annoyance throughout the interview with various aspects of his college experience. He does smile easily and uses a sarcastic tone to make his point at times. He reports not being pleased with some of the teachers and administration (personal communication, April 24, 2023, lines 36-37), not getting support from the university (personal communication, April 24, 2023, lines 340-348), and not finding a solid group of friends or peer support while in college. Struggling to find a friend group or support system is a theme in this interview. He states, Making friends is not that easy (personal communication, April 24, 2023, lines 299-300), and having anxiety makes social participation difficult (personal communication, April 18, 2023, lines 83-84). He was active in the tabletop role-playing gaming club but reports he did not gel with that club (personal communication, April 24, 2023, line 320). He enjoys going to sporting events but typically will go alone (personal communication, April 24, 2023, lines 322-323). He attempted to reach out for help from the campus while struggling with mental health issues during COVID-19. He felt he was not taken seriously and dismissed (personal communication, April 24, 2023, lines 340-348). He also feels dismissed when people offer solutions or coping strategies such as yoga, a planner, meditation, and journaling (personal communication, April INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 88 24, 2023, lines 282-283), as indicated by his tone of voice and body language while discussing these suggestions. He does find support from his mom, his therapist, and his psychiatrist. Another theme that emerged is the prevalence of stress in his life. PB was diagnosed with anxiety in 7th grade (personal communication, April 24, 2023, line 74) and reports additional diagnoses of depression and ADHD (lines 356-357). He feels as though there is always a stress level in his life, and it is hard to know or recognize when he is not feeling stressed (lines 192194). His symptoms of stress include becoming physically hot, getting upset, a hand tremor, increased heart rate, feeling more alert, sensitive startle response, struggling to think clearly, and shutting down. There is a decreased IA of hunger when stressed or playing video games. PB expressed frustration with being late and how being late impacts his stress levels, habits, routines, and participation in daily occupations. PB reported feeling frustrated at a Model UN event in which going to dinner would make them late, which elevated his physiological stress symptoms, and others downplayed his acute stress symptoms (personal communication, April 18, 2023, lines 96-104). He went on to identify how he would skip activities of daily living (ADLs) to avoid being late (personal communication, April 18, 2023, lines 113-115) or not attend class if he thought he would be late (personal communication, April 18, 2023, line 119). PB is aware that his main coping strategies are avoidance and distraction. He reports, I feel so bad Im just gonna go to sleep (personal communication, April 18, 2023, lines 184-185). He reports using video games, TV, or other media to distract himself in addition to sleeping. When playing video games, he can go for hours without eating and not feel the interoceptive cues of hunger (personal communication, April 18, 2023, lines 376-377). He also reports not being aware of that affecting his emotional regulation (line 388), another component of IA. He INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 89 does use sensory input to address stress, as demonstrated by his fidgeting with a baseball during the interview (personal communication, April 18, 2023, line 400). The overall essence of the interview is that PB is disappointed in his college experience and lack of understanding surrounding his mental health. He is aware of his stress levels but not necessarily the impact that IA plays in his reactions to stress or chosen coping strategies. While avoidance is used as a coping technique, it also interferes with his IA, namely hunger. He reports that sleep is not for being tired but for avoidance or distraction (personal communication, April 18, 2023, lines 205-206). To take care of his mental health, PB has professional help built into his routine. He also adjusted his schedule and made arrangements to address his mental health throughout his college career (personal communication, April 18, 2023, lines 43-44). He looks forward to actively participating in media platforms and enjoys the radio show he hosts (personal communication, April 18, 2023, line 66). Future suggestions for this study would be to ask participants to complete a survey to determine if they are more or less aware of their physiological interoceptive sensations when experiencing stress or during chosen coping strategies post-interview. C Participant C (PC) is a 22-year-old Caucasian female who is a senior working towards an Exercise Science degree at a mid-sized, private Midwest college. She plans to pursue a Masters Degree in Exercise Science to work in cardiac rehabilitation. Going away to school was a big decision, but she is grateful her sister is at the same college, making it less overwhelming and scary (personal communication, April 27, 2023, line 28). PC discusses the awareness of her growth over the last four years. She describes herself as someone who enjoys the challenge of school and is driven. Throughout her journey, she feels she found ways to allow herself to INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 90 explore her interests instead of stressing about picking a major (personal communication, April 27, 2023, lines 62-70). She has allowed herself some grace with not needing to have everything planned out. Overall, PC is proud of her academic and athletic achievements in college. Being an active swimmer and making great friends have been the most rewarding elements of college for her. Being away from her mom and her coursework has been the most difficult. PC can see how taking more challenging classes has pushed her to work harder and recognize when to get help. Asking for help was difficult, and she is glad that she finally did reach out in some of her classes (personal communication, April 27, 2023, lines 108-118). When asked about a definition of stress, PC initially stated it was a difficult question but was able to identify both sides of stress. She stated that stress can be good at times but thinks of stress as something that is a negative, draining, kind of overwhelming feeling (personal communication, April 25, 23, lines 135-137). Signs of stress for PC include feeling crabby or grouchy, shutting down or zoning out, and feeling exhausted or with no motivation. When feeling grouchy, she reports her sister will ask her if she has eaten (line 157). The physiological interoceptive sensations she experiences are tiredness, tense muscles, and hunger. With hunger, PC reports going between stress eating and having no appetite but not being aware of what triggers one or the other (personal communication, April 27, 2023, lines 181-183). Stress eating seems to be the most distressing for her. She feels full and sluggish after eating what she perceives as too much (personal communication, April 27, 2023, lines 238-244). She does not seem to mind that she is more alert when stressed, as indicated by her tone of voice and facial expressions (line 184). PC appears to struggle more with physiological interoceptive sensations when not stressed. She can identify that she is calm and relaxed but has difficulty INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 91 describing those sensations in her body. She is aware she is more active, feels less tired, and has normal hunger (personal communication, April 25, 2023, lines 197-200). Coping strategies include physical activity, movies, family, friends, and her sisters dog. Physical activity tends to be the most effective means of managing stress, as demonstrated by the awareness of how calm she feels after swimming, going to the gym, and walking the dog. She mentions physical activity four times and how much that helps to calm her. PC also mentions talking to family and friends several times as a coping strategy and a huge help. She also recognizes the need to talk to others before she is at the point of crying to better manage her stress (personal communication, April 25, 2023, lines 262-263). The overall essence of the interview is that PC is a high-achieving person who values hard work in academics and athletics. Her family, especially her mom and sister, are a valuable support system to her. The personal growth PC experienced over the last four years is something that she finds cool (personal communication, April 27, 2023, lines 63-70). She is aware that being a high achiever can be a source of stress, but she sought help and allowed herself time to choose a major she really enjoys. Her physiological interoceptive sensations are more intense when stressed, and she chooses coping strategies that decrease those sensations. Future suggestions for this study would be to ask participants to complete a survey to determine if they are more or less aware of their physiological interoceptive sensations when experiencing stress or during chosen coping strategies post-interview. D Participant D (PD) is a 21-year-old Caucasian female who is a junior working towards an exercise science degree at a mid-sized, private Midwest college. She has plans to pursue a Doctor of Physical Therapy degree, but the admission process is a source of stress and one of the INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 92 most challenging parts of college for her (personal communication, May 4, 2023, lines 78-82). PD reports being a pessimistic person and tends to struggle with confidence in her abilities (personal communication, May 4, 2023, lines 224-226). She is thankful for the support and encouragement she receives from her mother. PD reports her college experience was rough to begin with, identifying being distraught when she first started school due to COVID restrictions, not knowing her roommate, and feeling lonely (personal communication, May 4, 2023, lines 236-241). However, joining the soccer team increased her social participation and gave her an outlet for her stress (personal communication, May 4, 2023, lines 68-72). While PD refers to her college experience as a little different several times, she does not necessarily see that as a bad or negative experience (personal communication, May 4, 2023, lines 47-63). PD defines stress as sort of like having this apprehension or anxiety towards something youre currently dealing with or something that is like coming up (personal communication, May 4, 2023, lines 85-86). PD can recognize how stress can be both detrimental and motivating. She feels the stress of maintaining a specific GPA and getting good grades allows her to work harder toward her goals (personal communication, May 4, 2023, lines 93-96). While exploring the concept of stress, PD discussed racing thoughts, worrying, and having nagging thoughts. The physiological interoceptive sensations she experiences when stressed, are increased heart rate, feeling tired, getting sweaty, fluctuating hunger, and feeling jittery (personal communication, May 4, 2023, lines 101-105). Although she could identify her physiological interoceptive sensations, she had not heard of interoception before this interview. PD brought up stress eating and views the negative feelings that result from stress eating as I couldnt control my INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 93 psychological appetite instead of actual hunger or drive for hunger (personal communication, May 4, 2023, lines 189-191). PD engages in many positive coping strategies, such as going to the gym, reading, watching TV, and reaching out to her support system. The support system includes her mom, boyfriend, friends, roommates, teammates, and the pet cat in the apartment. She can identify that she feels calm and comfortable when relaxed but struggles to identify specific physiological interoceptive sensations related to no longer feeling stressed (personal communication, May 4, 2023, lines 166-168). Her support system helps her feel less overwhelmed by talking her thoughts through (personal communication, May 4, 2023, lines 215-220). The overall essence of the interview is that PD can use her stress as a motivator for success. She uses several positive coping strategies and can connect with others when feeling overwhelmed. PD focuses more on the top-down concepts of stress, such as worry, nagging, and racing thoughts. Being tired and bored Future suggestions for this study would be to ask participants to complete a survey to determine if they are more or less aware of their physiological interoceptive sensations when experiencing stress or during chosen coping strategies post-interview. E Participant E (PE) is a 21-year-old Caucasian and Hispanic female senior at a mid-sized, private Midwest college. She was accepted into a Doctor of Physical Therapy program postgraduation. PE is proud that she is in the Doctor of Physical Therapy program and credits her hard work and motivation to getting accepted. She has a bubbly personality and is engaged throughout the entire interview. She has a strong family and friend support network but is incredibly close to her mother. INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 94 PE feels being active and making connections have been the most rewarding part of her college experience. She is a member of the bowling team, plays intramural sports, is a member of Phi Eta Sigma, and has participated in Green Life and the Kinesiology Club. She also does personal training, has an internship, and works in the admissions office. All of this is on top of taking 15 to 18 credit hours. While being active and engaged is a source of pride, PE also admits that maintaining a healthy life balance has been a problematic part of the college experience. PE defines stress as Probably just like high feelings or anxiety or like your minds kind of going 1,000,000 miles per minute and you have tolike constantly be keeping up with everything (personal communication, May 8, 2023, lines 71-73). PE acknowledges that she has a diagnosis of ADD (personal communication, May 8, 2023, lines 127-128), and this impacts her thinking and response to stress. The awareness of the heightened need to fidget, along with racing thoughts, is the highlight of her stress response. She feels stress can be motivating as well as debilitating. She knows that stress changes her personality from talkative and bubbly to withdrawn and not as talkative (personal communication, May 8, 2023, lines 112-115). Stress affects habits and routines by making daily tasks and occupations challenging (personal communication, May 8, 2023, lines 96-101). PE experience of stress is related to the symptoms she experiences with having an ADD diagnosis. PE reports racing thoughts and feeling an increase in the need to move her hands, using fidget tools to assist with addressing this sensation (personal communication, May 8, 2023, lines 183-187). Other physiological interoceptive sensations she experiences with stress include a change in appetite, feeling drained, and having no motivation. She reports feeling a heightened sense of her physiological interoceptive sensations when stressed. She realizes that it is easier to understand when she is not feeling stressed (personal communication, May 8, 2023, lines 153- INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 95 155). Hunger is the hardest to interpret when stressed (personal communication, May 8, 2023, lines 159-161). To manage her stress, PE enjoys watching television, using fidgets, aerial yoga, and having a spa session alone or with her roommates. She reports feeling a sense of control when using the fidgets (personal communication, May 8, 2023, lines 219-222). Many of her coping strategies are sensation-based and provide a sense of calm or relaxation. She has a positive support system in her mom, brother, boyfriend, and friends/roommates. PE is aware that her high achievement drive can lead to perfectionism, and her coping mechanisms gets me through it because it kind of brings everything back (personal communication, May 8, 2023, lines 265266). PE is also aware that her experience of stress is more cognitive, then moves to the physical realm regarding the need to fidget (personal communication, May 8, 2023, lines 270-272). She does report getting injured initially while doing aerial yoga. The overall essence of the interview is that PE is a hard worker and uses the stress of school as a motivator for success. She is an energetic and bubbly person who is positively connected to her support system. She uses several positive coping strategies and can connect with others when feeling overwhelmed. Future suggestions for this study would be to ask participants to complete a survey to determine if they are more or less aware of their physiological interoceptive sensations when experiencing stress or during chosen coping strategies post-interview. F Participant F (PF) is a 19-year-old Caucasian male who is a freshman working towards a Communications degree at a mid-sized, private Midwest college. PF is a student-athlete and is proud of the work he has done with the track team. Track was part of his decision to not only INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 96 attend this college, but the team has been a large part of his support system. He beams when he talks about track and does feel it has been the most rewarding experience in college thus far (personal communication, May 10, 2023, line 37). He is hard-working and is currently taking 17 credit hours. He feels the initial transition to college was overwhelming with managing his schedule, but he could manage the increased workload this semester (personal communication, May 10, 2023, lines 25-27). While he feels he can manage the workload, he does report that classes and managing relationships have been the most challenging or complex part of the college experience (personal communication, May 10, 2023, lines 60-69). He is realizing the nuances of friendships and determining what type of relationship is worth it to him (personal communication, May 10, 2023, lines 66-69). PE defines stress as being overwhelmed and spreading myself too thin (personal communication, May 10, 2023, lines 101-102). PE experiences stress cognitively by becoming too hard on himself, allowing problems to appear much bigger than they really are, and begins to feel like people do not really like him (personal communication, May 10, 2023, 104-105). The idea of people not liking him becomes a theme and source of stress for PF throughout the interview. He reports getting stressed and then feeling like his interactions with others are not as good as they could be (personal communication, May 10, 2023, lines 173-179) or feeling like others think he is a joke (personal communication, May 10, 2023, lines 354-362). He recognizes that he becomes grumpy and less inclined to socialize with others when stressed. The physiological interoceptive sensations PF experiences when stressed include loss of appetite, feeling tired, getting a headache, and poor focus. He was not aware of the term interoception before the interview and did keep the flyer at the end of the interview. The most prevalent interoceptive sensation is tiredness. PF reports missing practice or not going to class INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 97 due to listening to the cues from his body to rest, but he also attributes that to stress affecting his habits and routines (personal communication, May 10, 2023, lines 123-124). PF is aware of his need for sleep and tries to ensure enough sleep to feel focused and ready to complete his daily tasks (personal communication, May 10, 2023, lines 226-229). He reports trying to meditate but did not feel like it was too helpful. PF also acknowledged that he experienced tendonitis this year and wondered if the toll stress was taking on his body contributed to his injury (personal communication, May 10, 2023, lines 254-258). Positive coping strategies for PF include sleep, being with friends and family, and running. The overall essence of the interview is that PF enjoys the challenge and work that school and track provide. He values sleep and will listen to his physiological interoceptive sensations when tired and honor those sensations. He is a deep thinker and can get caught up in his own thoughts when experiencing stress. He acknowledges that he may be the biggest source of stress in his life by trying to do too much and then getting overwhelmed (personal communication, May 10, 2023, lines 286-289). PF also recognizes how becoming too cognitive or cerebral with his stress affects his self-perception and interactions with others. He does value communication and will express those thoughts to his family and friends for validation and support (personal communication, May 10, 2023, lines 270-274). While he was not sure of what the term interoception was initially, he was able to communicate an understanding of the concept throughout the remainder of the interview. Future suggestions for this study would be to ask participants to complete a survey to determine if they are more or less aware of their physiological interoceptive sensations when experiencing stress or during chosen coping strategies post-interview. G INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 98 Participant G (PG) is a 19-year-old Caucasian female who is a freshman working towards psychology and sociology degrees at a mid-sized, private Midwest college. PG is friendly and easy to talk to during the interview. PG disclosed the diagnoses of depression and anxiety and discussed how those diagnoses had been intertwined with her lived experience of stress. She feels there is never a time when she does not experience stress, which is part of her life (personal communication, May 12, 2023, lines 169-172). While taking a high credit load, she does not recognize this as a source of stress but rather a positive of being challenged while in college. She feels that having the opportunity to learn has been one of the most rewarding parts of her college experience thus far (personal communication, May 12, 2023, lines 104-105). PG defines stress concerning her experiences with depression and anxiety as constant worrytheres also, I feel like a type of burnout with stress as well that I feel like I definitely experience as well as feelings of being burnt out and having no motivation (personal communication, May 12, 2023, lines 128-138). PG did not understand the term IA and used the handout to assist with identifying physiological interoceptive sensations. The physiological interoceptive sensations she experiences are tiredness, tension, soreness, increased heart rate, and variations of hunger. She feels like she is able to experience a state of being less stressed when her heart rate is down, and she feels less alert (personal communication, May 12, 2023, lines 239-242). PG engages in a variety of coping strategies to manage her stress, anxiety, and depression. She does yoga, performs self-care tasks, tries to be with friends, and sleeps. As stated earlier, she feels less stressed when she is less alert and will engage in cannabis use occasionally to escape the alertness (personal communication, May 12, 2023, lines 257-261). In the past, PG used cutting as a means of coping but was able to end that behavior with the help of her INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 99 support system, medication, and therapy (personal communication, May 12, 2023, lines 331370). She currently still chews on the skin around her fingernails, but does not engage in cutting (personal communication, May 12, 2023, lines 337-344). The overall essence of the interview is that PG works hard at school but tends to ignore or want to escape her feelings regarding stress. PG grew up in an abusive household and feels she always has a degree of stress but tries not to pay attention to or recognize those signals within herself (personal communication, May 12, 2023, lines 434-436). Interestingly enough, PG did not think she was experiencing any stress until she came to the interview and began to discuss her physiological interoceptive sensations (personal communication, May 12, 2023, lines 440-442). Her coping skills focus on soothing her sensory system, as indicated by her need to take breaks from socializing, engaging in spa sessions, and the use of cannabis. Future suggestions for this study would be to ask participants to complete a survey to determine if they are more or less aware of their physiological interoceptive sensations when experiencing stress or during chosen coping strategies post interview. This may determine if PG is able to recognize her physiological interoceptive sensations sooner and manage her stress levels better in the future. H Participant H (PH) is a 22-year-old Caucasian female who is a senior graduating with a degree in Human Performance and Exercise from a mid-sized, private Midwest college with a plan to transfer to a Masters of Therapeutic Recreation program. PH appears nervous at first, fidgeting with her hair and skirt initially, then becoming more animated and talkative as the interview progresses. PH describes an overall positive college experience, especially after switching her major from exercise science to her current major. She reports having a total INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 100 mental breakdown her junior year, which led to her switching, and feels it has been the best decision for her (personal communication, May 15, 2023, lines 22-28). Her mental health is a theme throughout the interview, along with her ability to grow from her lived experiences. PH reports coming to college and making that transition alone was one of the most difficult experiences, along with learning how to manage her time and stay organized (personal communication, May 15, 2023, lines 57-77). She describes various instances where relationships with roommates have been difficult, but overall feels she has created some rewarding relationships (personal communication, May 15, 2023, lines 54-55). Another part of her lived experience that she finds rewarding is watching her personal growth. She reflected on how her growth as an individual and all the experiences she had (personal communication, May 15, 2023, lines 48-52) allowed her to feel ready to move on to her next college experience (personal communication, May 15, 2023, lines 452-453). PH discusses her lived experience with stress in relation to her diagnoses of anxiety and depression. She defines stress as just likefeeling overwhelmed. I guess, not being able to handle the situations presented to mein a more relaxed manner? (personal communication, May 15, 2023, lines 91-93). The result of the stress is panic attacks, anxiety attacks, feeling overwhelmed and emotional, crying, increased crying, and stress eating (personal communication, May 15, 2023, lines 101-128). She reports being aware of how much stress affects her sleep and how that impacts the rest of her day. Some other physiological interoceptive sensations are an increased heart rate and shaking hands (personal communication, May 15, 2023, lines 141-150). She did not connect stress eating to interoception and stress until looking at the handout, wherein she stated, Thats interesting several times while discussing her eating habits (personal communication, May 15, 2023, lines 159-163). However, PH may benefit from INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 101 further exploration of the physiological interoceptive sensation of hunger because there was a contradiction in how she experiences hunger. At one point, she discusses feeling hungry all the time and not getting enough to eat, then states that she struggles with stomach problems and needs to force herself to eat (personal communication, May 15, 2023, lines 159-169). Cueing into those varying sensations may assist her with identifying hunger needs. PH enjoys a variety of coping mechanisms, but combining music with spiritual care seems to be her main source of calming herself (personal communication, May 15, 2023, lines 182-203). She reports listening to spiritual music, or Jesus Music (personal communication, May 15, 2023, lines 182-187), helps her calm down, focus, and sleep better (personal communication, May 15, 2023, lines 201-205). She also engages in self-care activities (personal communication, May 15, 2023, lines 216-226) and any type of interaction with animals (personal communication, May 15, 2023, lines 333, 336-339, 347-350, 354-355, 359-361, 456-470). Communicating with her mother through talking and journaling has been especially helpful in dealing with negative thoughts of self-harm and overall mental health (personal communication, May 15, 2023, lines 270-304). Therapy has also been beneficial (personal communication, May 15, 2023, lines 270-272). PH can recognize that she is calmer after engaging in these coping strategies, noting her sleep and focus are improved. She does engage in alcohol use occasionally as a means of giving herself a hard mental reset (personal communication, May 15, 2023, lines 211-216). The overall essence of the interview lies in the fact that PH is proud of the accomplishments she has made despite having depression and anxiety that can interfere with her life. She wishes more people understood what it means to have anxiety, as that misunderstanding has been a source of stress with former roommates and her dad (personal communication, May INTEROCEPTIVE AWARENESS AND COLLEGE STUDENTS 102 15, 2023, line 379-383, 393-394). She is aware of the IA of feeling calm, able to focus, and improved sleep. Still, she could benefit from paying more attention to the physiological interoceptive sensations surrounding hunger when experiencing stress. Future suggestions for this study would be to ask participants to complete a survey to determine if they are more or less aware of their physiological interoceptive sensations when experiencing stress or during chosen coping strategies post-interview. ...